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LIBRARY OF CONGRESS. 

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Slielf,:..C.:b„. 



UNITED STATES OF AMERICA. 




. CASE OF 

EMPEROR FREDERICK III. 



Full Official Reports 

BY THE I; 

OKRIVEAN PHYSICIANS 

AND BY 

Sir MORKLIv IVIACKKNZIK. 





<Z^ 



The Reports of the German Physicians Translated by 

HENRY SCHWEIG, M. D. 




NEW YORK : 
48 University Place, 

EDGAR S. WERNER, 
1888. 



Copyright by 
EDGAR S. WERNER, 



TRANSLATOR'S PREFACE. 



He that is without sin among you, let him first cast a stone. — John viri., 7. 

In January, 1887, the Crown Prince of Germany felt the initial 
symptoms of the illness to which he finally succumbed on June 15, 
1888. 

The case from the moment that it presented symptoms of a grave 
character was watched with keenest sympathy and interest by the 
whole civilized world ; and when the courageous struggle for life 
was finally ended there were few, it can be assumed, who did not 
feel that the world had lost a man who, aside from his brilliant 
qualities, had done much to endear himself to all who had come in 
contact with him. 

While sorrow was still uppermost in the hearts of those who 
mourned his early death, and before, we may say, the earth had 
settled on his grave, in fact, during his life, strange rumors of pro- 
fessional differences and bickerings began to take form, culminating 
finally, after his decease, in the appearance of a report, claimed to 
be official, of the German and Austrian physicians who had been 
connected with the case. This report gave not alone the pro- 
fessional history of the illness from its commencement, but con- 
tained, in addition, charges of such a grave nature reflecting on the 
professional skill and integrity of the gentleman who had been 
called in consultation and under whose sole charge the case had 
been finally placed (Dr. Morell Mackenzie) that the impression that 
the Emperor had been sacrificed, as it were, to professional wran- 
gling, gained ground. Following the report, another, in response, 
appeared denying not only in ioto the allegations in the preceding 
one, but imputing to the German physicians methods of intrigue, 
unprofessional conduct and want of skill both shocking and cruel. 

It is certainly very unfortunate that a controversy which should 
have been conducted on a purely professional basis has degenerated 
into crimination, recrimination, and has had introduced a vitupera- 
tive element certainly not in accord with the standing of the men 
indulging in it. 

The two publications differ more in degree than in kind, and 
abound in statements which we cannot characterize other than 
ludicrous. The assertion touching Dr. Mackenzie's want of skill in 



iv TRANSLATOR'S PREFACE. ■ 

the use of the laryngeal forceps and his inability to properly reflect 
the hght from his head-mirror is as humorous as the statement that 
a surgeon of von Bergmann's skill was not sufficiently well-versed in 
the technique of tracheotomy to insert a tube, but was compelled to 
accomplish it by proxy. A case is not necessarily proven by a 
series of abusive statements, nor do charges and counter-charges of 
a lax handUng of truth constitute evidence that the world would care 
to accept. We cannot understand why physicians should depart 
from their subject for no other purpose, as far as we can see, than to 
say unkind things about their confreres, and we are loath to believe 
that if these reports had been written one year later that the spirit 
of anger would have dominated their pages to the same extent. 
Outside of the medical facts as accepted by both the German and 
the Enghsh contingent, no opinion regarding the case could, with 
justice, be called absolutely correct, as no one would have the 
temerity to question the veracity of any of the gentlemen who are 
on record in the case, and the most charitable construction which 
could be put on the reports would be that they are the outcome of 
conclusions too hastily arrived at by reason of a supposed question 
of professional skill or wounded honor. How those portions of the 
reports which are diametrically opposed can be reconciled on other 
grounds than stated above we fail to see, and it must be left to the 
reader to judge as to their respective merits and reliability. 

It is unnecessary to dwell upon the statistics of partial or complete 
extirpation of the larynx. At best, they give us only the results of 
operations performed, and do not permit us to speak with anything 
approaching certainty of what the result in this case might have 
been. True, statistics are the only data on which to base a prognosis 
in cases of the kind under discussion, and we do not think that the 
statement that a patient's life could have been prolonged for a 
definite time by a certain method of procedure is one whit more 
temperate than the assertion, or at least, the insinuation, that the 
patient's life might have been saved by an early operation. Division 
of the larynx for the removal of benign as well as malignant growths 
is an operation of too recent data to enable us to speak authorita- 
tively on the subject, more particularly as up to a very short time 
ago it was resorted to only as a dernier resort, and not under con- 
ditions favorable to a successful issue. We know of no case anal- 
ogous to the one under consideration in which an operation was 
undertaken at a date as early in its history as when operative inter- 
ference was suggested by the German surgeons, and we are not 
prepared to say what the result might have been. On the other 
hand, it is a question how prudent it would be to treat all cases of 
laryngeal cancer entirely by endolaryngeal measures. It seems to 



trantlatoe: s preface. v 

us that it would have been in much better taste to conduct this dis- 
cussion in circles entirely professional, and to keep from the laity 
the harrowing details of a professional wrangle. What should have 
been a clear and concise statement of facts based upon the personal 
observations of the different members of the medical council, has 
become a vehicle for the ventilation of personal feeling, and a report 
which should have been handed down as a scientific production of 
great value showing, as it does, the grave errors into which men of 
learning and skill are sometimes apt to fall, has become an abusive 
document which, from a scientific standpoint, cannot be character- 
ized other than a hollow mockery. 

The pitiful exhibition of temper, which is shown in both the 
English and German reports, compels the reader to wade through 
a mass of irrelevant matter, so that he may follow the medical thread 
of the report understandingly. An element of personal sj^ite, 
jealousy and animosity has crept into the pages, and there is perhaps 
no medical report of which we are cognizant into which so much 
matter entirely foreign to the subject has been introduced. The 
report of one of the gentlemen shows the possibility of giving an 
opinion purely professional in tone and strictly to the point. With 
this one exception, the bearing of the parties engaged in this con- 
troversy has not elevated the standard of the medical profession in 
the eyes of the general public, whose faith in the correctness and 
reliability of physicians' opinions was much disturbed thereby. If 
medical men cannot be at variance at the bedside regarding the 
diagnosis of disease without exhibiting petty jealousy, the interests 
of patients would be far better served if their cases were entrusted 
entirely to one person. The meeting of the Enghsh physician 
with the German medical advisers of the Crown Prince was the 
starting-point of dissension which, from that moment, steadily grew 
and flourished. Subsequent events prove beyond peradventure 
that some of the suggestions made from time to time would, had 
they been followed, have redounded to the benefit of the illustrious 
patient. It is to be hoped for the sake of professional honor, if 
not of common decency, that the pubhcation of the secrets of 
the bedside will not again become public property, and that pro- 
fessional men, whose sole aim should be to do that which will best 
serve the interests of their patients, will not so far forget themselves as 
to lose sight of the main issue in the endeavor to belittle each other 
in the eyes of their confreres and of the whole world. 

Henry Schweig, M. D. 

New York, November 15, 1888. 
26 East 20th street. 



PAGE. 



CONTENTS. 

PART FIRST. 
Reports of the German Physicians. 

CHAPTER I. 
Report of Dr. E. Gerhardt i 

CHAPTER II. 
Report of Dr. E. von Bergm ann 17 

CHAPTER III. 
Report of Staff-Physician Dr. Landgraf 28 

CHAPTER IV. 
Report of Prof. Schrotter ' , 35 

CHAPTER V. 
Report of Dr. Moritz Schmidt 42 

CHAPTER VI. 
Report of Dr. Bramann 51 

CHAPTER VII. 

Report of Dr. von Bergmann (Continued) 58 

CHAPTER VIII. 
Report of Dr. Kussmaul 68 

CHAPTER IX. 
Report of Dr. Waldeyer 72 

CHAPTER X. 
Report of Dr. von Bergmann (Continued) 76 

CHAPTER XL 

Report of Prof. Bardeleben 87 

CHAPTER XII. 

Autopsy of Emperor Frederick III 92 

CHAPTER XIII. 
Microscopical Report of Profs. Virchow and Waldeyer 
OF Specimens from the Remains of Emperor Freder- 
ick III 95 



viii CONTENTS. 

PART SECOND. 

Report of Sir Morell Mackenzie. p^ge. 

Preface 99 

CHAPTER XIV. 
First Visit to Berlin and Potsdam loi 

CHAPTER XV. 
Second Visit to Potsdam 117 

CHAPTER XVI. 
The Crown Prince in England 127 

CHAPTER XVII. 
ToBLACH — Venice — Baveno 137 

CHAPTER XVIII. 
San Remo — The Worst Fears Confirmed 141 

CHAPTER XIX. 
San Remo — Suspense 1 50 

CHAPTER XX. 
San Remo — The Tracheotomy 155 

CHAPTER XXI. 

Charlottenburg 1 84 

CHAPTER XXII. 
The Emperor's Last Stay at Potsdam 218 

CHAPTER XXIII. 
The Epilogue 226 

CHAPTER XXIV. 
The Truth about the Proposed Operations 232 

CHAPTER XXV. 
The Indictment 245 

CHAPTER XXVI. 
Results of Recorded Operations 262 



ILLUSTRATIONS. 



FIGS 



PAGE. 

1 . Sketch of the growth as first seen 104 

2. Sketch of growth after first operation 108 

3. Sketch of growth after the third operation 117 

4. Sketch made June 28, showing the larynx after complete 

removal of the growth 1 128 

5. Sketch showing Mr. Hovell's observations on September 9, 137 

6. Sketch made November 6, showing new growth 141 

7. Bramann's canula 160 

8. An ordinary full-sized canula 161 

9. Bramann's canula (half size) in situ 162 

10. Diagram showing Durham's tube used too late 170 

11. The San Remo canula shown in position 176 

12. A surgical probe bent at right angles near its distal extremity, 177 

13. The probe foreshortened 178 

14. Diagram showing how the probe would have appeared on 

each side, if Dr, Bramann had opened the trachea in the 
median line 179 

15. Diagram with half the trachea removed, showing measure- 

ments inside , 180 

16. Durham's tube acting well 187 

17. Durham's tube (full size) twisted to left side 189 

18. Diagram showing the part into which von Bergmann plunged 

the canula 201 

19. Diagram showing von Bergmann's false passage 202 

20. The extremities of von Bergmann's unprotected, and Dur- 

ham's guarded canula 204 

21. Diagram showing abscess resulting from the false passage. . 207 

22. The last canula used 209 



^ I ^ 

THE REPORTS OE 

THE GERMAN PHYSICIANS. 



CHAPTER I. 



REPORT OF DR. E. GERHARDT, PROFESSOR AT THE ROYAL 
UNIVERSITY, AND MEDICAL PRIVY COUNCILLOR, IN BERLIN. 



The Beginning. 

His Imperial and Royal Highness, the Crown Prince of the Ger- 
man Empire and of Prussia, was attacked in January, 1887, by a 
persistent and progressive hoarseness. The stubbornness of the 
ailment could be explained by the fact that His Imperial Highness 
had occasion to use his voice frequently, and that therefore those 
measures calculated to guard the voice against the influence of cold 
were neglected. The ailment is said to have commenced with 
symptoms of an ordinary cold, and the diagnosis of catarrhal 
hoarseness was accepted at the time. During the following 
months there was neither cough nor any catarrhal manifestation, 
only a dry hoarseness. The various remedies usually of benefit in 
cases of catarrh, as well as the employment of inhalations, gave 
entirely negative results. 

On March 6, 1887, in conformity with the wish expressed by Dr. 
Wegner, I made a laryngoscopic examination. The vocal bands 
showed moderate but general redness. During the respiratory act 
there appeared plainly on the edge of the left vocal band, between 
the vocal process and its middle third, a trifle nearer to the former, 
a pale and apparently uneven projection. The length appeared to 
be about 4 millimetres, the height about 2 millimetres. During 
phonation, the bands approximated closely, and at the point afore- 
said there projected an elongated, low, pale red nodule, which 
encroached on the vocal fissure. 

During the respiratory act the bands moved freely from the 
median line, and the whitish-red projection became again visible in 
its entirety. This projection followed the movements of the vocal 
bands freely, /. e., no rigidity or difiiculty of motion was apparent. 
The hoarseness seemed dependent on the encroachment of the new 
formation on the vocal space, interfering with the proper vibrations 



2 CASE OF EMPEROR FREDERICK III. ' 

of both vocal bands. The diagnosis of polypoid thickening of the 
left vocal band was made. Therapeutic measures were necessary to 
remove the growth. The next few days were occupied in educating 
the throat of the noble patient to the introduction of sounds and 
instruments. The use of cocaine to facilitate this was well borne, 
even in the strong solutions of lo and 20 per cent. The narrowness 
of the glottis, as well as painfulness of the tongue on manipulation, 
and a few smaller obstacles, required time and patience to con- 
quer. The first attempt to remove the growth by means of a wire 
snare slightly bent to the right, with which it was proposed to 
operate, resulted only in the removal of a small, white lamella from 
the surface of the growth, having the same characteristics as the 
.growth itself; that is, a slight hardness to the touch. Later attempts 
to remove the growth with the aid of a circular knife were negative 
in their results, the hardness, smoothness and flatness of the new 
formation making this procedure useless. This led to the selection 
of the galvano-cautery as the destructive agent to be employed. 

On the morning of the 14th another careful examination was 
made by sunlight. On this occasion a sharp line of demarcation 
between the edge of the vocal band and the growth was clearly 
discerned. In addition to this, there appeared immediately below 
the edge of the vocal band, at the place above-mentioned, and 
immediately anterior to the vocal process, a flat, uneven elevation^ 
having its origin at the inner portion of the vocal band, visible only 
during respiration. The vocal fissure during phonation appeared 
uneven at this point. The color was whitish-red, the surface not 
smooth. On the evening of the 14th the incandescent platinum wire 
was first employed. Examination revealed a white eschar, the band 
reddened in its entirety. There was an immediate improvement in 
the voice, followed by slight hoarseness, and then permanent im- 
provement. In the evening and on the following morning there 
was slight pain on deglutition. 

On the 1 6th the growth was cauterized in its entirety, with special 
reference, however, to its centre. As a result, improvement of 
the voice was noted. The cauterization gave little pain. On the 
1 8th the growth appeared much flatter, separated in the centre by a 
groove, pale red in color, the vocal bands slightly reddened at their 
margins, and no motor disturbance of the left vocal band, the voice 
showing marked improvement. From the i8th to the 26th, treat- 
ment was suspended on account of the birthday celebration of His 
Majesty, the Emperor William. 

On the 26th, the growth appeared whitish in color, flat, with some 
elevations, and now in length about j4 cm., and smooth on the 
surface. During phonation it encroached on the posterior commiss- 



DR. GERHARDTS REPORT. 3 

ure. From this day on, on the 26th, 27th, 29th and continuing 
daily until April 7, daily destructive cauterizations with the incan- 
descent wire were practiced, and all projections were removed by 
cauterization. On the 7th the edge of the vocal band was cauter- 
ized and smoothed by a flat burner. Examinations on the 8th and 
9th, by sunHght, showed moderate redness of the left vocal band and 
slight concavity at a place corresponding to the anterior portion of 
the growth, which had entirely disappeared, showing at its former 
site an uneven, reddish, granulated surface at the edge. The gen- 
eral condition of the patient was splendid, no cough, no expectora- 
tion, the voice still hoarse, but much more resonant than formerly, 
and better in the morning than in the evening. The pain on deg- 
lutition spoken of above, and which only appeared occasionaUy, 
was now continuous ; it is true only sHght, and its existence only 
established on questioning the patient, but still an evidence of a 
pathological condition. The noble patient at the time felt as if he 
had almost entirely recovered. 

Preceding the first examination, Dr. Wegner had projected a 
stay in Ems for his patient, to give his voice, which had been much 
taxed, a few weeks' rest, a proceeding which could only be praised. 
When this subject was again broached by Dr. Wegner in the begin- 
ning of April, and the day of departure decided upon, the advisa- 
bility of destroying every vestige of the growth urged itself upon 
us. The stay in Ems could have nothing but a beneficial effect 
upon the wounded surface, which would result from further surgical 
interference. On the 13th the departure took place. On the 7th 
the growth had been removed, and on the succeeding days the sur- 
face appeared smooth and everi, although the process of repair did 
not seem to go on. To guard against any possible infection, inhal- 
ations were used from the beginning of April, the medicament em- 
ployed being a solution of i in 2000 ot bichloride of mercury, and 
chloride of sodium. The journey to Ems, however, had a still 
further significance. In the beginning of April, I had misgivings 
regarding the nature of the growth. At that time we were con- 
strained, in spite of its rather unusual appearance and location, 
to look upon and treat it as benign. Its removal was called for. 
No one at the time would have been justified in standing idle and 
allowing the new formation to grow and enlarge. Prompt removal 
was necessary. If it proved benign, the patient would be cured. 
If malignant, the fact would be established by its prompt return. 
Now, the growth was destroyed, and it behooved us to watch 
whether, with absolute rest and under the most favorable surround- 
ings, there would be a return of the evil. The journey to Ems 
would determine this. 



4 CASE OF EMPEROR FREDERICK III. 

The Diagnosis of Cancer. 

Benign tumors of the vocal bands, polypi, so-called fibromata, 
papillomata, adenomata, etc., develop, in the majority of cases, at 
the anterior third of the vocal bands. The seat of the growth in 
question called for special notice. Papilloma or papillomatus 
growths appear mainly at this site. If this growth were benign, the 
inference was that its correct appelation would be papilloma. Ac- 
cording to the classification of Oertel, it belonged to the second 
form of papilloma. The appearance of the growth, however, was 
different from that of the ordinary papilloma. It was broader, inti- 
mately connected with the edge of the band, was more a thicken- 
ing than an excrescence of the interior of the vocal band. During 
the use of the galvano-cautery the surface appeared hard, broken in 
an uncommon manner, and presented appearances such as I had in 
frequent examinations of benign tumors failed to witness ; every 
day showed some change m appearance. I, however, continued 
my work under the impression that I was dealing with a benign 
tumor. When the ordinary snares and knives failed by slipping 
from the surface, and when that which the incandescent wire 
destroyed in one day re-appeared in part on the following, my 
doubts were aroused. Once, before the birthday of the Emperor, 
I had destroyed the larger part of the growth with the cautery, and 
eight days later the growth was larger than before. The task now 
before us was by daily cauterization to thoroughly destroy the 
growth, until the vocal band lay before us in its normal shape. 
This was done from March 29 to April 7. But the resulting open 
surface neither healed nor suppurated ; it simply remained an 
open surface. Benign growths of the larynx may grow again, but 
only subsequent to the healing process following cauterization, when, 
in a longer or shorter period, a return may take place. This case 
differed. Under the slough the growth returned at once. So, in 
the beginning of April, my fears had been already aroused. We 
had before us a patient at the age in which cancer of the larynx 
most frequently occurs, a growth which looked differently and acted 
differently from a benign tumor, and reminded one of cases of car- 
cinoma. My doubts in the matter were not kept from the physician, 
Dr. Wegner ; on the contrary, they were mentioned to him seri- 
ously. Doubts they were, it is true, but strengthened by many col- 
lateral facts. But it was necessary to see clearly in the matter, and 
to find corroborative evidence of either one or the other form of 
disease, let us say polypus or cancer, without delay, and to decide 
according to the facts before us. I then expressed the opinion that, 
after a rest of a few weeks in Ems, we should be able to judge 



DR. GERHARD rS REPORT. 5 

whether the base of the growth had healed or not, and whether a 
new growth was developing. I opined that after two weeks we 
could arrive at a certain diagnosis, and gave a carefully written list 
of the places where I could be found during this time. 

A. still further diagnostic point was to be a factor in the decision. 
The development of cancerous growths of the vocal bands, even at 
an early period, leads to more or less rigidity, so that the bands 
become weak and restricted in their movements to a much larger 
degree than the appearance of the growth would lead one to 
believe. Up to this time, this symptom was absent; both bands 
moved equally well. If, with the re-appearance of the growth, the 
mobility of the left vocal band became impaired out of proportion 
to its physical character, the existence of a malignant growth could 
be assumed. 

The newspaper reports from Ems were not reassuring. A few 
days prior to the return of our noble patient I received word from 
Dr. Wegner that the presence of a laryngologist had been de- 
manded. I took this occasion to visit the gentleman aforesaid and 
again to call his attention to the gravity of the situation, and to beg 
him at the same time that, in case the growth had re-appeared, 
which I inferred from the newspaper reports, or if the vocal band 
had become more rigid, to concur with me in my opinion that only 
a surgeon should be called in consultation. Any number of laryn- 
gologists might be consulted, but a surgeon would be, provided the 
diagnosis was correct, the only one whose interference would be at 
this stage of any avail. Staff-physician Dr. Schrader, who hap- 
pened to be present at the time, supported me in my opinion that it 
would certainly be proper to guard ourselves against subsequent 
blame in the matter, i. e., that we had only then recognized the 
disease when it was too late to remedy it even surgically. 

We went over the history of our noble patient very carefully, to 
discover, if possible, any point of departure for his present illness. 
Dr. Wegner assured us that anything which might have been attrib- 
uted to any infectious trouble (a subject touched upon later by 
persons not properly informed) could be excluded. The neck showed 
no glandular enlargements ; the pharynx showed a slight catarrhal 
tendency, and there were no signs of scars anywhere visible. In a 
word, there was no ground on which to base any such suspicion as 
before mentioned. 

Could this be a case of tuberculosis ? This rarely leads to large 
laryngeal growths, and our noble patient had not had fever, nor 
cough. His lungs were in normal condition, and he was the picture 
of health. This could also be excluded. This narrowed the field 
to the diagnosis of either benign or maUgnant laryngeal growth, 



6 CASE OF EMPEROR FREDERICK III. 

namely, polypus or cancer. I confess that for weeks my forebodings 
had been decidedly gloomy. I could not dismiss the thought of 
cancer. The distressing fears that had disturbed me for many 
sleepless nights I at last determined to dispel. I formed a resolution 
that if, after weeks of rest at Ems, the tumor grew rapidly, and the 
mobility of the left vocal band became impaired, then I would give 
the decisive word, but firmly and without reservation. 

On April 13, our noble patient had left for Ems. On May 15 he 
returned to Potsdam. On this day the voice was much worse than 
before, the growth decidedly larger. It formed a marked convexity 
on the upper portion of the vocal band, and was covered with an 
injected, reddened mucous membrane. At its inner surface it 
appeared flat, uneven, and grayish-red, the open surface left after 
the cauterization showing no tendency to cicatrization. Its posterior 
boundary was separated from the vocal process by a fissure more 
marked than appeared at the previous examination. The move- 
ments of the left vocal band were decidedly more sluggish than 
those of the right one. My worst fears had been realized. I did 
not conceal from our noble patient the fact that the growth had 
again appeared. He expressed the wish that treatment with the 
galvano cautery be immediately continued. I begged for delay ; 
begged that in conformity with previous instructions one or more 
laryngologists be present, mentioned the four most prominent 
specialists in this branch in Berlin, and then added my request that 
a surgeon, namely. Privy Councillor von Bergmann, be called in, as 
the tumor with which we had to deal was of a nature in which the 
judgment of a surgeon would be desirable. This proposition was 
accepted, and the selection of a laryngologist postponed until Dr. 
von Bergmann's opinion had been added to ours. To Dr. Wegner 
was assigned the matter of calling von Bergmann into consultation. 
I did not speak with him regarding the case, and neither had nor 
looked for any means of determining his view of the case. He 
made an examination on the i6th, and promptly suggested that on 
account of the possibility of malignancy, at any event, on account 
of the persistent reappearance of the growth, a division of the 
larynx and a thorough extirpation of the new formation was indi- 
cated. After the consultation, Dr. Wegner again broached the 
matter regarding consultation with a laryngologist. Numerous 
names were mentioned, Wegner suggesting Dr. Mackenzie, von 
Bergmann and I concurring, as we found the laryngosco()ic appear- 
ances and the history of the case so clear, that any one with any 
knowledge of laryngoscopy would necessarily concur in our opinion. 
The correctness of this supposition did not seem open to doubt after 
the 1 8th. On this day a most important consultation took place, to 



DR. GERHARD TS REPORT. 7 

which there were sent by His Majesty, the Emperor, His Excellency, 
von Lauer, and Privy Councillor Tobold. There were also present 
Drs. Wegner, Schrader, von Bergmann and I. Privy Councillor 
Tobold made a careful laryngological examination, and said, after 
we had repaired to the consulting-room, that every other diagnosis 
could be dismissed, the case being clearly one of cancer. The other 
consultants concurred in this opinion, and an early opening of the 
larynx and removal of the growth was recommended. 

The diagnosis of cancer made on the i8th by the above-named 
six physicians was based on : 

1. The rapid recurrence of the growth. 

2. Its hardness and uneven surface. 

3. Absence of process of repair at its inner surface. 

4. Impaired mobihty of the vocal band. 

5. On the certainty with which tuberculosis and other infectious 
diseases could be excluded. 

6. On a train of co -existing circumstances. 

Among the latter might be mentioned the age of the patient, the 
seat and appearance of the growth, the circumstance that destruc- 
tion of the surface resulted neither in suppuration nor in the healing 
process, and in also a number of etiological factors and diagnostic 
observations peculiar to the case. 

The diagnosis in this case was arrived at so much earlier in its 
history than in the majority of instances, and seemed to be as 
soundly based on data as was possible at this stage — at any rate, it 
appeared so certain that the consulting physicians were all ready to 
take upon themselves the responsibility of any results that might 
follow from interference based upon their opinion. 

Although it is a fact that a number of cases of sarcoma of the 
larynx*, and one of carcinoma of the larynxf, were removed byway 
of the mouth and cured, there appeared no possibiHty of a cure by 
way of the mouth in this case, if we accepted the diagnosis of 
cancer ; as the attachments of the growth were such as to assume 
that its boundaries were not very clear, and as it appeared to spring 
from the deeper portions of the vocal band, to say nothing of its 
flatness. In this case, all thoughts of an operation by way of the 
mouth were dismissed, the proper operative procedures being those 
laid down eighteen years ago by Desormeaux. The necessity of 
dividing the larynx was apparent. This to-day, with our many ap- 
pliances and aids, is an operation almost without danger, frequently 
resorted to where there are benign tumors, and in the cases of 
patients of advanced years as well as of children. Only in this 

* Sidlo, " oesterreich med. Jahrbuch X. Schech, v. Ziemssen^s Archiv XVL" 
t B. F-raenkel. v. Langenbeck's Archiv Bd. 34 S. 281. 



8 CASE OF EMPEROR FREDERICK III. 

way would it be possible to thoroughly root out the laryngeal disease 
in all its ramifications, and leave no germ of the former evil. The 
diagnosis of the physicians had, at an early date, determined the 
nature of the ailment. The surgical contingent had the most favor- 
able case to deal with : That of a man of splendid physique, with 
the strength of a giant, in whose case the task set was to remove a 
small growth of the diameter of half a centimetre, from the larynx. 
The seat of the growth, which projected from the edge of the vocal 
bantl, would facilitate its removal materially. There are no statistics 
which would do justice to the probabilities of the favorable issue 
that might be expected in this case founded upon such favorable 
data, for in no instance was the disease recognized at so early a 
dale, at its inception I may say, and in no instance was the consti- 
tution of the patient so robust. All aids to success stood at our 
command. It was a question at the time whether the operation, 
which was necessary, should not be confined to the soft tissues alone, 
or whether it would be necessary to remove a small portion of the 
thyroid cartilage. Serious doubts existed on this point. The voice 
would certainly be impaired by the removal of the larger part of the 
vocal band. But what is the voice in comparison to life ! Withal, 
it might be expected, as in analogous cases, that a hoarse though 
loud voice might be retained. 

On the evening of the 20th all preparations for the operation, 
even to the minutest details, had been made. On the following 
forenoon the operation was to take place. 



In Contradiction. 

In Ems the services of a laryngologist were first suggested, as 
rumor has it, by the physician then and there in charge of the case. 
When I, according to instructions, had named four of our local 
laryngologists, the matter was postponed until alter von Bergmann's 
consultation. At the consultation on the evening of May 16, Dr. 
Wegner suggested Mackenzie, while we spoke of others. We finally 
accepted Mackenzie. He came for consultation on the evening of 
the 20th, there being present all the physicians who had previously 
consulted. Mackenzie was given a detailed report regarding the 
previous history of the case, as well as observations and opinions. 
He made an examination and declared at once that he did not take 
this to be a case of cancer, the entire appearance of the tumor being 
anything but cancerous, and he would be opposed to an operation 
such as the one proposed until microscopic examination of a piece 
of the growth demonstrated clearly its cancerous nature. The post- 
ponement of the operation until the microscope should decide was 



DR. GERHARDTS REPORT. 9 

agreed upon. Mackenzie was entrusted with the task of removing 
a specimen, Virchow being decided upon to make the microscopic 
examination. On the morning of the 21st Mackenzie removed a 
small piece of tissue. Immediately after this I noticed a slight loss 
of substance of the mucous membrane at the upper portion of the 
left vocal band, near the outer margin of the growth. At the base 
of this place there lay denuded yellow elastic tissue. Virchow's 
examination revealed irritative processes, but there was an isolated 
nest of concentric epithelial cells (a cell-nest in fact), in the midst of 
prolifierating epithelium. Even at that time he gave his opinion 
orally that the case might be one of pachydermia laryngis. It was 
urged as an objection that the specimen was not taken from the 
growth proper. Mackenzie, therefore, endeavored to secure a 
further specimen. On May 23, in the evening, at Potsdam, he 
again introduced the cutting-forceps. I saw him take the forceps 
from his breast-pocket, introduce it without previous cleansing, and 
that during its introduction the illuminating rays which he projected 
on the laryngoscope from the head-mirror deviated to one side, illu- 
minating the cheek of the illustrious patient instead of the mouth. 
The forceps were withdrawn empty. He did not care to operate 
any further that day. I made an examination at once, and found 
both vocal bands much reddened, the right one in its entirety 
ecchymosed, and at the edge of the right vocal band, a little in 
front of the middle third, a blackish-red swelling projecting into the 
glottis. I begged Dr. Wegner, asking him not to mention the 
circumstance, also to make an examination. He did so, and assured 
me he could find nothing. We repaired to Mackenzie's room, and 
I there told him that he had grasped the until then healthy right 
vocal band instead of the left one with his strong forceps, and had 
bruised and torn it. He answered, " It can be," and then spoke of 
his immediate departure. We suggested that he should at least 
remain in Potsdam over night, and Dr. Wegner mentioned to him 
the name of a military surgeon who might assist at tracheotomy, if 
it became necessary. 

The noble patient was from this date, until quite a time after his 
visit to England, voiceless; had pain during the succeeding days on 
both sides of the neck, and a feeling of obstruction. This is per- 
haps the first well-authenticated case in which a laryngologist, 
through carelessness, endeavored to tear a piece out of a healthy 
vocal band. The illustrious patient, who formerly, though hoarse, 
was never voiceless for more than three hours, was from this time 
on and for many weeks, namely, until July 8, without voice ; and 
later, in England, it was looked upon as a triumph of medical skill 
that his hoarse voice was restored to him ! On May 25, there was 



lo CASE OF EMPEROR FREDERICK III. 

again a medical consultation, at which Drs. von Bergraann and 
Tobold became convinced that the right vocal band had received an 
injury in its centre. On the 28th this injury had so far changed that 
the redness of the vocal band had diminished, and that at the point 
of injury a yellow, blunt projection encroached on the vocal fissure. 
On June i, there was a loss of substance at the right vocal band, 
appearing yellow and purulent, the length being 3 to 4 millimetres, 
breadth i to 2 millimetres. From Landgraf's reports the injury 
could be looked upoiiras repaired on June 29. 

On May 24, Dr. Wegner and I met in consultation with Macken- 
zie in Potsdam. In certain circles the report was already current 
that Mackenzie had promised the family of the noble patient to 
cure the malady radically in a few weeks without operation. To the 
attending physicians he had not said one word touching the subject. 
I therefore urged him, on the evening of the day of our meeting in 
his room, to outline for us his plan of treatment. His response was, 
and this Dr. Wegner wrate down at the time, that the tumor must 
be removed by the cutting-forceps, following which the galvano- 
cautery was to be apphed ; or that the same result might be ob- 
tained from the continued use of the galvano-cautery. He further 
stated that he preferred the former method ; and, following out this 
course, he would, in time, fully restore the voice. In response to 
my question as to whether he could assure us that this would be so, 
he answered, " Yes, with certainty," and then added, after a pause, 
" humanly speaking." 

On the 25th another general consultation was held, in which it 
was determined that Morell Mackenzie should remove the tumor 
with the cutting-forceps and the incandescent platinum wire, as he 
assured us of his ability to accomplish this, and, furthermore, that 
the voice would be entirely restored. His assurance was, perhaps, 
not as emphatic as on the day previous. Von Bergmann, on this 
occasion, stated very decidedly that, according to his view, the 
neoplasm was of the malignant order. Tobold expressed his doubts 
as to the practicability of removing the tumor in its entirety with 
the forceps, and that it would be only a question of time when a 
cutting operation would be required, and sounded a note of warning 
against too frequent operative interference, as this would tend to 
stimulate the growth of the tumor. I declared at the time that I 
did not believe that the tumor could be removed by way of the mouth, 
but that if Mackenzie assured us of his ability to do so he might pro- 
ceed, but only until such time when the tumor should prove, on 
microscopic examination or through the history of the case, to be 
mahgnant. Morell Mackenzie, of his own accord, stated that he 
would operate according to the manner explained by him until the 



DR. GERHARDTS REPORT. ii 

removal of a portion of the growth proved its malignancy, or until 
such time as the growth should recur. 

Commencing on the 23rd, and in accordance with the expressed 
wish of Mackenzie, Dr. Wegner used daily insufflations of a powder 
•composed of morphine, bismuth, catechu and sugar. We saw the 
cancer grow and blew in an innocent powder ! Great faith in 
Mackenzie's promises was general. It is a peculiarity of laryngeal 
cancer that for a long time it remains a local ailment, and the gen- 
eral health is imimpaired. The world was pleased with the good 
appearance, the strength and apparent vitality of the noble patient ; 
and those who claimed that the ailment was a slight one, unattended 
by danger, gained the approbation of those who were not informed 
as to the true state of affairs. 

My last careful examination was made on June i. The growth 
was then larger, still suppurating at its inner surface, its posterior 
line of demarcation more clearly and deeply marked against the 
vocal process, and at this point the inequality and destructive pro- 
cess began to encroach upon the posterior wall. The left vocal 
band was, as at former examinations, less freely movable than the 
right one. The pain was intermittent, but there was no difficulty in 
breathing. Dr. Morell Mackenzie, who, in the meanwhile, had 
gone to England and returned, again extirpated on June 8 two pieces 
of the growth in Potsdam. On this occasion he found means to keep 
such an inconvenient witness as I was away. The examination of Prof. 
Virchow revealed an epithelial proliferation, with papillary process 
(erroneously called papilloma), pachydermia verrucosa. He ex- 
pressed, however, his doubt as to the propriety of accepting his 
opinion as to the growth in its entirety, as this could not be given 
with any degree of assurance from the examination of the two pieces 
furnished him. This opinion was read at a general consultation 
held on June 10, and, at Mackenzie's desire, made public. At this 
consultation von Bergmann gave it as his decided opinion that cli- 
mate had no bearing on the progress of a case such as the one 
under consideration. 

Mackenzie assured us that the climate of the Isle of Wight would 
hasten the healing process. Our words were useless. The journey 
to England had been decided upon. How the decision was arrived 
at, only Mackenzie knew, none other of the attending physicians. 
At a consultation in the house of Dr. Wegner on June i,at which 
von Lauer, von Bergmann, Schrader and Tobold were present, it 
was resolved that, as the journey to England could not be prevented, 
two wishes should be expressed : First, that all portions of the 
growth, which should be removed, were to be sent to Virchow for 
examination ; secondly, that the treatment in England should be 



12 CASE OF EMPEROR FREDERICK III. 

under the control of a German physician well informed in laryngo- 
scopy. 

At that time public opinion leaned strongly, and was shared also 
by the medical faculty, toward the view that the German physicians 
had erroneously diagnosed cancer, and had planned a bloody and 
destructive operation ; that, however, Mackenzie had saved the life 
of his noble patient by promising him results which made such an 
operation unnecessary. The whole power of the press was made 
use of to spread this opinion. What was the growth if not cancer ? 
According to Mackenzie, it never was cancer. At various times he 
denominated it as a wart without a root, as papilloma, as laryngitis, 
as perichondritis, or as laryngitis and perichondritis. He never 
gave us a clear, tangible diagnosis ; only in his denial of cancer was 
he firm. The reasons which Mackenzie gave for not accepting the 
diagnosis of cancer were as follows : First, that the tumor did not 
look like cancer. Against such a reason no argument can be used. 
Secondly, that a portion of the growth must show microscopically its 
cancerous nature. In those diseases the causes of which are clearly 
established and are apparent in every microscopic section, such an 
opinion might be accepted, as, for instance, in tiiberculoHS, actina- 
mycosis, and anthrax. Such general dissemination of pathological 
products has, up to date, not yet been established in cancerous 
growths. The very laudable efforts to discover a specific germ of 
cancer, which stands in causative relation thereto, has, up to date, led 
to no recognized results. Our position to day regaiding the diagnosis 
of cancer is at that point at which tuberculosis was before Koch's dis- 
covery of the tubercle bacillus. A tumor may, as stated in the classic 
case mentioned by Virchow in his work, vol. i, page 349, consist 
mainly of harmless proliferating tissue, containing carcinomatoiis tis- 
sue in only one small portion. Still, the history of such a case proves, 
as in the above instance, that, although the anatomist may declare the 
growth benign, as, for instance, fibroma, it may still be malignant. 
It is of rather common occurrence that cancerous growths are sur- 
rounded by smaller benign hypertrophies. Virchow bore this in 
mind when he in every instance declared that only the portion ex- 
amined by him was not cancerous. Mackenzie concluded, and that 
erroneously, that Virchow's examinations were proof that the whole 
tumor was non-malignant. He wrote on June x to the editor of 
the German Revue, for the purpose of publication : "I am happy to 
be able to state to you that the microscopic examinations of Prof. 
Virchow have estabhshed beyond a doubt that the disease is not 
cancer." He must have known that Virchow possibly examined 
only httle processes of the growth, and that a malignant nucleus 
might be there. The history of the case had been clearly described 



DR. GERHARDTS REPORT. ' 13 

to him, and should have commanded a certain amount of consider- 
ation, which it did not receive. 

On the occasion of the last consultation, when we stated to 
Mackenzie that the tumor had enlarged, was encroaching upon the 
posterior wall, that the motion of the left vocal band was not suffi- 
ciently free and was more sluggish than the right one, his answer was ; 
" I cannot see this." Later, he wrote, in a report published in San 
Remo, that the impaired mobility of the left vocal band had already 
been diagnosed in Berlin. Is it possible that he, too, recognized this 
fact in Berlin ? 

For a time the report was current and accepted that the disease 
in question was not cancer, but pachydermia verrucosa laryngis. 
This was based on the report of Virchow's examination of small 
pieces of the growth. This was of little use, for such a thing as a 
cHnical history of this disease does not exist. Neither in the work 
on tumors by Virchow, nor in Mackenzie's "Diseases of the Larynx," 
nor in any other work could a word touching this disease be found. 
All that had at the time been written on the subject was a disserta- 
tion by Hiinermann (Berlin, 1881), which, like the paper by 
Virchow, read later, gave positive points only as far as the anatomy 
was concerned. Besides, there were three reasons against accepting 
this opinion. 

First, pachydermia is essentially a disease of the drunkard. This 
could be dismissed at once in this case. Secondly, pachydermia is, 
in nearly all instances, bilateral. This was acknowledged by 
Jiirgens, who first described the disease at a meeting of the 
physicians of the Charite, held March 29 of this year. In the case 
before us, the ailment was for many months confined to one side. 
Thirdly, pachydermia is a disease which progresses slowly, while in 
this case its rapid growth was a marked feature from the first. In 
conclusion, the opinion of Mr. Lennox Browne must not be forgotten, 
to the effect that the evil was primarily benign in its character, but 
was made malignant through irritating operative interference, more 
especially through my galvano-caustic treatment. The full doctrine of 
this transformation is believed in by few. The statistics of Felix 
Semon show that in 8,300 cases of benign tumors, only 40 were said 
to have degenerated into malignant ones — said to have. Most people 
would see in this the statistics of human diagnostic errors, not of 
transformations and degenerations. 

In every case of a small, new formation at the edge of the vocal 
band, where its character has not been clearly determined, it 
becomes a duty to resort to removal at once. What physician 
would stand idly by with folded arms and allow it to grow and not 
interfere, so that he might not make it malignant ! If such a 



14 CASE OF EMPEROR FREDERICK III. 

neoplasm is destroyed and recurs with alarming rapidity, then, of 
course, it would be wrong to delay division of the larynx, so that 
free access could be had, to extirpate it root and branch. Does 
Lennox Browne mean to insinuate that the galvano-cautery has the 
peculiar property of transforming polypus into cancer even more 
quickly than Mr. Mackenzie's forceps, which, in this case, were 
guilty of inflicting gross injuries on the larynx ? Granted that it 
were proven that with more or less frequency, say in one-half per 
cent, of the cases, as Semon's statistics seem to indicate, benign 
tumors did degenerate into cancer, still this would not be any proof 
that certain methods of treatment have any influence on this process, 
either for or against, and still less that this obtains in the case before 
us. It is a trebly unsupported assertion, which was here given to 
the public. 

The Journey to England. 

The journey to England was to have for its object (having been 
planned, as stated, without the knowledge of the attending physi- 
cians and against their advice), according to Mackenzie, the effect 
of the healing properties of the air of the Isle of Wight on such 
diseases as the one affecting our noble patient. The decided 
opinion of von Bergmann that chmate had no effect whatever on 
such processes, that benign as well as malignant laryngeal growths 
could be as well treated here as in any part of England, was 
answered by Mackenzie with a simple negative as to von Bergmann's 
statements. Subsequent events proved that the air of the Isle of 
Wight had so little effect on the healing process that Mackenzie 
himself found it incumbent on him to suggest to his noble patient 
a journey to Scotland. Neither the air of Toblach, Baveno, nor of 
San Remo was of any avail in the matter of curing or checking the 
disease. 

As agreed at a consultation held at the house of Dr. Wegner on 
the ist, there being present von Lauer, Wegner, Schrader, von 
Bergmann and I, the following desires were expressed : First, that 
the case be watched by a German physician versed in laryngoscopy ; 
secondly, that the treatment of Mr. Mackenzie go only so far as he 
himself had decided; that is, until the tumor proved malignant on 
microscopic examination of portions of the same, and that for this 
purpose all pieces removed be sent to Virchow for examination. 

Touching the first point, I had been asked a few days previously by 
the King's chamberlain, in conformity with an expressed wish of the 
noble patient, to accompany him to England, and placed myself in 
readiness to obey this command, begging, at the time, that Dr. 
Wegner should likewise be asked to accompany us. 



DR. GERHARDTS REPORT. 15 

On June 6, in the evening, I learned that the above resolution 
had been in so far modified that Dr. VVegner was to be the sole medi- 
cal companion. On the above evening, that is, the 6th, I urged the 
recognition of that which had been determined upon at the consulta- 
tion, and succeeded in Dr. Wegner's proposing the addition of Dr. 
Landgraf to the party, which was acquiesced in. This seemed to 
ensure the necessary and urgently needed control of the case. 

When I was notified by the above physician that he should forbid 
Landgraf to communicate with me in any way regarding the pro- 
gress of the case in England, I carefully avoided any communica- 
tion with my assistant Dr. Landgraf touching the subject in ques- 
tion. He was then acquainted by Dr. VVegner as to what his 
functions were to be, and with the previous history of the case. The 
last word which His Imperial Highness, the Crown Prince, spoke to 
me, was a pleasant and gracious one, and referred to the change in 
the matter of the accompanying laryngologist. The first official 
report of Dr. Landgraf from England, which was sent me by von 
Lauer, confirmed, though I had never spoken on the subject with 
Landgraf, my diagnosis on June i, with one small and easily ex- 
plained exception : He did not find a breach of surface of the 
growth. Landgraf 's report on June 18 was as follows : 

" The right vocal band is reddened, somewhat swollen, and shows 
a small excavation directly opposite the tumor. On the left vocal 
band there is a pyramidal pointed tumor, with broad base, directed 
upward and backward, covering the posterior fourth or third of the 
band. The tumor is pale yellowish-red in color, there being no 
marked redness either in the tumor or in the surroundings. On the 
left side, on the anterior portion of the posterior laryngeal wall, the 
raucous membrane is thickened. On adduction the movements of 
the left band seem to be more sluggish than on the right side. 
During phonation the glottis shows an opening. No ulceration, 
but total aphonia." 

On the 17th, Mr. Mackenzie sent Dr. Wegner the following re- 
port, which was officially submitted by him : " No congestion. 
Condition favorable." He claimed to find no defect on the right 
vocal band, and attributed the aphonia to the projection of the 
swelling on the left band, which interfered with the proper approxi- 
mation of both vocal bands. With the exception above stated, 
Landgraf found all that which I had noted on June i, but which 
Mackenzie did not see here, and the existence of which he also 
denied in England, namely, the redness of the right vocal band, the 
irregular form of its margin, the encroachment of the morbid pro- 
cess on the posterior wall of the larynx, and the impaired mobility 
of the left vocal band. 



1 6 CASE OF EMPEROR FREDERICK III. 

On June 26, Landgraf found that the raucous membrane of the 
upper portion of the larynx was paler than before ; hkewise the 
right vocal band, the injury to which was still visible. The tumor 
on the left vocal band had increased in size rather than decreased, 
and was no longer pointed, but rounded ; between the tumor and 
the posterior laryngeal wall accumulation of mucus ; mobility of 
the left band impaired as heretofore. Following this, I received one 
more report from Landgraf, which was submitted to me by von 
Lauer. 

On July I, Landgraf finds (after Mackenzie's operation of June 
28) the larynx reddened, the excavation on the right vocal band 
and the swelling on the left side no longer visible ; but on the pos- 
terior wall well-marked tumefaction, grayish-yellow in color. Land- 
graf saw this on July i. Later, on the Isle of Wight, Mackenzie's 
attention was called to a thickening of the mucous membrane at the 
posterior portion of the arytenoid cartilage by his assistant, and he 
then also saw it. {Berliner klinische Wochenschrift, vom 21. Novem- 
ber, 1887.) 

From this time on I received no further communications regarding 
the progress of the disease. 

After the consultations of November 9 and 10, 1887, Sir Morell 
Mackenzie declared openly : "Although the nature of the newly- 
formed growth has not been clearly determined, it certainly presents 
the appearance of a carcinomatous neoplasm." 



CHAPTER 11. 



REPORT OF PROFESSOR AND PRIVY MEDICAL COUNCILLOR 
DR. E. VON BERGMANN. 



On the evening of May 15, 1887, 1 was requested by Dr, Wegner, 
the physician of His Imperial Highness, the Crown Prince of the 
German Empire and of Prussia, to meet him and Privy Councillor 
Prof. Gerhardt on the following day to examine the Crown Prince, 
and give my opinion of his ailment. At the same time Wegner 
informed me orally regarding the history of the case of the illustrious 
patient, stating also that the opinion of a surgeon was demanded, 
specially by Dr. Gerhardt. I concurred with Wegner in the opinion 
that, considering the importance of the case, it would be necessary 
to have present a specialist of note, the more so as I did not feel suf- 
ficiently well-informed in the matter of special diseases of the larynx, 
or in endo-laryngeal operations. As we were both of the opinion that 
among the noted specialists of diseases of the throat the Germans 
had none better known than Gerhardt, and none whose position 
was a higher one, it can be readily understood that we looked for a 
consultant to some one outside of our own country. I proposed 
Prof. Rauchfuss, of St. Petersburg, and one or the other of the two 
celebrated Vienna laryngologists, Schrotter and Stork. Wegner was 
of the opinion that Mackenzie, of London, whose work on diseases 
of the larynx lay before him at the time, would be the most proper 
person, a suggestion which I accepted at once. On May 16 and 18, 
1887, I made examinations. Already after the first examination I 
was convinced that the case was of epithelioma of the posteiior 
portion of the left vocal band. In accordance with this view I at 
once suggested laryngotomy, a procedure which I prefer decidedly 
to endo-laryngeal operation in cases of smaller carcinomata. Judge 
as we may, thyrotomy, laryngotomy, in fact all the operations 
designed to facilitate removal of intra-laryngeal growths, it is certain 
that during the last decade their occurrence is more and more fre- 
quent, and attended by far less danger and disastrous results. Of 
seven laryngotomies which I performed in Berlin, to which I may 
add two cricotomies, not one ended disastrously : all healed 



i8 CASE OF EMPEROR FREDERICK III. 

without any complications. (The Pall Mall Gazette as well as the 
Vossische Zeitimg are persistently pleased to describe me as the sur- 
geon who has never completed an operation successfully. " Dr. 
von Bergmann has not performed even one." I have not withheld 
from Mackenzie any of the successful issues in my operations.) I 
am not alone in my opinion regarding the safety of the operation. 
Many others, as Rauchfuss and Kohler, agree with me, and the 
work of Schuchardt, of Volkmann's clinic, " Ueber den ausseren 
Kehlkopfschnitt," states that " the dangers of laryngotomy were 
formerly much over-estimated, and are, at present, under thorough 
antisepsis, attended with very little danger." 

Under the circumstances one can readily understand that I 
advise division of the larynx in all those cases in which there is a. 
well-grounded suspicion of a malignant neoplasm in the interior of 
the organ. In the last four volumes of the " International Centralblatt 
fiir Laryngologie " we find 15 cases of laryngeal operations enu- 
merated; that is, thyrotomies and cricotomies. Of those operated 
on, one died, and that from diphtheritic infection ; all others 
recovered. 

It is a decided error to determine the value of an operation from 
information gathered from general medical literature, magazines, etc. 
Such reports, statistics, compilations, etc., simply give us data by 
which to judge individual cases. In reading over such reports, as. 
far as they concern extirpation of the larynx or portions of the same, 
we are forced to the conclusions which we have arrived at in mod- 
ern times regarding extirpation of other organs, such as, for instance, 
resection of the stomach, or intestinal tract. These new operations 
were resorted to in the beginning with expectations much too san- 
guine, and were, therefore, allowed too great a scope. It is to this 
fact, however, that we owe our early and exhaustive experience, 
which has resulted in our restricting operative interference to such 
cases only as promise ultimate good results. Those cases of total 
or partial extirpation of the larynx which resulted favorably, are 
those which existed relatively only a short time and were not wide 
in their extent. This accounts for the fact that the percentage of 
cases cured after partial extirpation of the larynx is a much higher 
one than where total extirpation was practiced. It is proper to 
state that in the former cases the growths were smaller than in the 
latter. As, according to our opinion, the cancer of the left vocal 
band of our illustrious patient was very small, the operation seemed to 
promise the best possible results. I must add that which Bramann's, as 
well as my, microscopic examinations in San Remo revealed, that 
is, the tendency to cornification of the epithelial cells and the carcino- 
matous deposits in the neoplasm. Judging by analogy from the 



DR. BERGMANN'S REPORT. 19 

cases of Hahn and Schede, these deposits promised the best possi- 
ble prognosis. 

Not a word was spoken in May. 1887, regarding any other oper- 
ation than the opening of the larynx as a means of extirpating the 
small growth that was at the left portion of the vocal band. This, 
in fact, was the only growth under consideration at the time. I 
desire to emphasize this fact, as the press, which attacked us, has 
been constantly pleased to speak of total extirpation of the larynx. 
Commencing in June, 1887, English as well as German papers 
lauded Mackenzie as the man who rescued the Crown Prince from 
the hands of the surgeons. The operation which we proposed was 
not more dangerous than ordinary tracheotomy, to which, accord- 
ing to our diagnosis, the Crown Prince would certainly, in the future, 
be compelled to submit. We, therefore, proposed only what was 
really unavoidable in the case. 

But how was my judgment, which taught me at the time to urge 
a speedy operation, construed ? I stood on the ground of personal, 
well-founded experience. It was then two, and it is at present more 
than three, years since I removed a laryngeal cancer from a patient 
42 years of age, by opening the larynx and resecting a portion of 
the cartilage. The man, whose name is Cygan, and who has been 
entirely well since that time, with no recurrence of the disease, is 
standing beside me while I write this. He is an industrious work- 
man in a North German printing-establishment, and although his 
voice is hoarse, it is still sufficiently strong to be heard at a distance 
of ten paces. As the examination of his larynx is most interesting, 
and specially designed to demonstrate the fact that the right vocal 
band goes well over to the left side during phonation, hugging the 
brilliant white scar closely, I invited Mackenzie, at the time, to 
examine the patient. I regret to say that he did not avail himself 
of the opportunity to do this. The appearances were those of the 
case described by Solis Cohen in the Medical News of 1887. This 
case referred to a patient on whom laryngotomy had been practiced 
20 years previously, with lasting success. Therefore the same oper- 
ation, which I had proposed in the case of our illustrious patient, 
was that which had been practiced on one who thereby had been 
cured of cancer. In the case operated on by me, the portion extir- 
pated, was recognized not alone by me but by my assistant Fehleisen 
and by Prof. B. Frankel, to whom I was indebted for the patient, as 
carcinoma. Frankel submitted his microscopic results to Prof. 
Waldeyer, who concurred in his opinion regarding the diagnosis. 
In addition to Hahn, in the case of M. W., well known in England, 
in which Paget made the anatomical investigations, there is a third 
one of Prof. Kiister, in which a cure was effected through partial 



20 CASE OF EMPEROR FREDERICK III. 

extirpation of a malignant laryngeal neoplasm. I refer to the case 
of Medical Councillor Fromm who was operated on by him seven 
years before, and whose hoarseness of voice did not for a moment 
keep him from the pursuit of his daily avocations. 

Granted that we had erred, that there was no cancer, but a benign 
new formation, the operation could not then have injured ouf illustri- 
ous patient, but the questionable diagnosis of Mackenzie would have 
been thereby verified. True, thyrotomy presents one gloomy feature : 
Disturbance of voice-production. But this does not necessarily fol- 
low. Rauchfuss, Bennett May, Parkes and others had practiced the 
operation for the removal of multiple papillomata from the vocal 
bands of children, where a good voice was preserved. It is for this 
reason that Schiiller, in his monograph on tracheotomy and 
laryngotomy, correctly states that the seat of tumors to be removed 
and their special characteristics, and not thyrotomy in itself, stand 
in causative relation to the phonetic disturbances that result. If we 
bear in mind the advice and instructions given by Schuchardt and 
Kohler, if we are careful and exact in the use of our knife, and ex- 
ercise care not to deviate from the median Hne, and take the precau- 
tion, as I do in my operations, to map out the line of incision with 
a short, stout knife before using the cartilage forceps, we shall not 
go wrong. 

The fissure of the larynx, as such, would not have modified the 
voice, nor endangered life. The former, however, would be neces- 
sarily affected by the removal of the tumor, whether the boundary 
of the mucous membrane were encroached on or not. But just in 
this respect, endo-laryngeal measures do not differ in any way from 
extra-laryngeal ones. If it were intended to remove the tumor, it 
was unavoidable to take away with it a piece of the vocal band ; the 
method of removal whether from within or without would not 
change the result in any way. I therefore felt constrained to men- 
tion the fact that the operation proposed by me would permanently 
injure the voice. We might expect a hoarse, rough voice ; but, if 
we were enabled to preserve the right vocal band in its integrity, the 
voice would still be sufficiently good for ordinary purposes. I was 
in a position, by referring to a number of persons known to His 
Imperial Highness, to suggest to him what the quahty of voice 
would be. 

To this explanation is due the fact that after our second exam- 
ination made May i8, 1887, Her Imperial Highness, the Crown 
Princess, instructed me to prepare everything for the operation, so 
that, on Mackenzie's arrival and when he had concurred in our 
diagnosis, the operation could be performed on the morning follow- 
ing, that is, on May 21. The illustrious patient himself said to me : 



DR. BERGMANN'S REPORT. 21 

" The swelling must go at all events. If you cannot remove it 
through the mouth, you must make an external incision." I 
acquiesced, and then commenced my arrangements to put the second 
story of the palace of the Crown Prince in order for the operation ; 
the rooms being divided into operating-room, sick-room and apart- 
ments for the physicians as well as for the attendants. I was 
assisted in this with untiring zeal by Her Imperial Highness, the 
Crown Princess, who looked well to it that not the smallest detail 
was forgotten, and that all the articles required by me were both 
new and well-cleansed. The operating-table, instruments, sterilized 
bandages, etc., were all in place on the evening of May 20. 

It is known how Mackenzie's flat opposition to our views rendered 
these preparations useless. I have very little to add to the report 
made by Privy Councillor Gerhardt on this subject. How 
unequivocal Mackenzie's rejection of my decided diagnosis of 
cancer was is evidenced by his remark : " I feel convinced that if 
your great interest in the beloved Crown Prince did not have full 
possession of you, and if the case were an ordinary one in your 
clinic, you would not even think of carcinoma." He also gave 
reiterated assurances that his rich experience had given him more 
than one case, identically the same, which had been cured through 
mild and soothing endo-laryngeal treatment. On this opinion was 
based his assurance to a number of gentlemen of the court that, 
after a few weeks' treatment in England, the Crown Prince would 
again be in full possession of his voice, and would certainly be in 
condition to take command at the military manceuvers in the fall. 
The same stand was taken by Mackenzie as described by a reporter 
of The World, November 23, 1887, in which he is made to say : " I 
am still of the opinion that at the time the disease was not cancer- 
ous. That which I saw in the larynx of the Crown Prince was, to 
my eyes, non malignant ; and I may be permitted to say that I have 
probably seen a greater number of such cases than any one living." 
I must not leave unmentioned my decided opposition to Mac- 
kenzie's use of Virchow's opinion of May 21, 1887. I have rarely, 
and I may say in only exceptional cases, succeeded in gaining 
through microscopic examinations anything of use to me for diag- 
nostic purposes, for it is a matter of chance and luck if we succeed 
in securing from an organized tumor, such as carcinoma, a speci- 
men characteristic of its nature. Virchow has very properly men- 
tioned this fact in more than one place in his celebrated Avork on 
tumors, as likewise Paget, Liicke, and also Mackenzie, who, in his 
work " Growths in the Larynx," London, 1871, page 36, says : " In 
those cases in which small particles are coughed up, or removed by 
the aid of the laryngoscope, we cannot depend upon the micro- 



22 CASE OF EMPEROR FREDERICK III. 

scope m making our differential diagnosis. I have met with many 
cases in which the histological appearances were decidedly those of 
cancer, while the clinical history was quite the reverse, and vice 
versa'' Even lately, Virchow writes : "I do not care to oppose 
this method of examination, as it is often the only one at our com- 
mand ; but we must not be surprised if it prove illusory. It is very 
possible that the infinitesimal fragments which are placed at the 
command of the investigator may come from a part other than the 
diseased one." In the case before us, it was hardly possible to 
reach that portion of the tumor in which characteristic elements 
might be contained, because it was located at the inferior portion of 
the vocal band, and possibly at the side of the lower portion of the 
larynx. This rendered practically impossible the removal of a 
fragment suited for examination. Mackenzie admits this in his 
translation into German of his book on " Diseases of the Throat 
and Nose," part I, page 437, and for this reason Gerhardt and To- 
bold declined to act in the matter. But Mackenzie, according to 
his communication to the Pall Mall Gazette, of May 17, 1888, attrib- 
utes this to an entirely different motive : " There were two Ger- 
man professors, specialists in diseases of the throat, present. They 
both declared that they were not competent to do that which any 
member of the medical staff in the Hospital for the Diseases of the 
Throat, in London, could have done at once, and which any stu- 
dent, after a year's instruction, might have done with ease." Mac- 
kenzie seized the upper and free margin of the vocal band with his 
forceps. It would, therefore, have been necessary for him to go 
through the entire thickness of the vocal band to reach the base of 
the growth in question. That he did not succeed in doing this, 
Virchow's examination of the specimen proves. I could not gather 
anything from Virchow's description other than a non liquet. The 
specimen which was given the anatomist was not sufficient to justify 
a definite conclusion ; certainly not that which Mackenzie, and the 
press, which was with him, accepted and formulated in the Pall 
Mall Gazette, June 15, as follows : 

•' Based on the pessimistic reports, which a number of London morning papers 
have published under their telegraphic news, touching the throat- trouble of the 
Crown Prince, the Pall Mall Gazette yesterday senta representative to Dr. Morell 
Mackenzie, to interview him regarding the sensational rumors. Mr. Mackenzie 
gave the reporter of the Pall Mall Gazette the following information : ' After the 
first fragment of the growth had been removed, Dr. Virchow declared that he 
required another portion for purposes of examination, but, at a later date, he 
stated to Dr. Wegner, the physician to the Crown Prince, that he felt thoroughly 
satisfied. The first examination had given negative results. No cancer was 
found, only inflammatory products. After the second operation, which Mac- 
kenzie performed after his return to Berlin, a much larger fragment was removed, 
and Dr. Virchow was in a position to give a positive opinion, which was to the 



DR. BERGMANN'S REPORT. . 23 

effect that the growth was a " thick-skinned wart." This is the common form of 
warty growths found in the larynx.' Dr. Mackenzie added that he did not take 
and did not propose to take any responsibility regarding the nature of the growth. 
He looked upon Virchow as assuming the entire responsibility in the matter. At 
the same time, he felt convinced that there was nothing in the growth which had 
the appearance of cancer." 

On a former occasion the British Medical Journal had given space 
to hke statements, but was set right according to our conception by 
ButUn, who, June 4, in No. 1379, wrote as follows : 

"The main points to which I wish to revert are, first, the result of the micro- 
scopic examination of the small piece removed by the forceps ; and, secondly, the 
manner in which our journals, I mean especially our daily papers, express them- 
selves regarding the 'triumph of British laryngeal surgery over the German.' 
Since the year 1883, when I called attention thereto ('Malignant Growths 
of the Larynx,' pages 26 and 43), I frequently have had occasion in my own 
practice, as well as in that of my colleagues, to examine such fragments. Through 
this I have come to the conclusion that it is misleading, even dangerous, to 
depend upon an examination based upon one specimen, unless, perhaps, in the case 
of diseases presenting special characteristics peculiar to them, for instance, epithe- 
lioma (cornificated). .When the structure of the fragment is of questionable nature, 
or of the kind which we frequently find in inflamed deposits, it is proper that before 
giving a decided opinion a second, even a third, fragment be removed. One or two 
recent cases have demonstrated the necessity of care in this direction, and have 
shown that neglect in this regard has led to improper treatment. Touching the case 
of the Crown Prince, I am informed that the fragment removed was very small ; 
and, owing to the tumefaction of the surrounding structures, could be removed only 
with great difficulty. I greatly admire the marvelous manual dexterity of Dr. Morell 
Mackenzie, but I realize how difficult it is, under existing circumstances, to remove, 
with anything approaching certainty, a fragment well designed for a decisive exam- 
ination. We are all ready to acknowledge the superiority of Prof Virchow in micro- 
scopic examinations, but even he can only give an opinion based on a specimen sub- 
mitted to him. Up to date, the case is still in a very uncertain light, and a number, 
I may say very many of us here, still entertain great fears regarding the nature of 
the illness of the Prince. The events of the last few days certainly do not fur- 
nish evidence that Dr. Mackenzie's view is correct and that of the Germans incor- 
rect ; and I therefore earnestly hope that our periodicals, be they edited by laymen 
or by medical men, refrain from indulging in expressions of triumph until they 
are in a position to substantiate the correctness of the assertion that Mackenzie 
has supported the reputation of EngHsh medical science in the outside world." 

In the same number Felix Semon expresses himself in the same 
tone. 

If, in the face of this, many of our German and British colleagues 
still viewed Virchow's opinion in a different light from that of Vir- 
chow himself, as expressed in the meeting of the Berlin Medical 
Society, Nov. 16, 1887, it may have been owing largely to the pub- 
hcation (unfortunately printed at the same time) of Virchow's lectures 
on pachydermia laryngis (June 27 of that year); the more so, as a 
sentence by this author, in an article on June 20, had the effect of 
suggesting whether possibly the pathological anatomist had not over- 
stepped his bounds, and had not interpreted according to the speci- 



24 CASE OF EMPEROR FREDERICK III. 

men which had been submitted to him, but had added his views to 
those of the dinician, and then formed his entire picture of the 
disease. I refer to the sentence in the second column, of page 445, 
of the Berliner klinische Wochenschrift, where it is stated: "You 
characterize the malady (meaning, of course, in its entirety), as an 
epithelial degeneration with papillary growths, pachydermia verru- 
cosa." What Virchow really thought, and what his judgment was, 
he stated at the meeting of the BerHn Medical Society, on Nov. 16, 
1887. 

The progress and sad ending showed plainly how well grounded 
were Butlin's as well as our own fears. 

After the last consultation, we had lost that confidence in 
Mackenzie which originally had prompted us to call him in con- 
sultation. We were driven to this, in the first place, by his unreli- 
ability in the matter of laryngeal manipulation, which did not justify 
us in the belief that his instrument really reached the tumor, and not 
another portion of the interior of the larynx, as, for instance, the 
notoriously injured right vocal band. In the second place, by the 
unscientific and entirely arbitrary opinion opposed to his own 
doctrines as well as to Virchow's, and by his shirking the responsi- 
biUty, and transferring it to the pathological anatomist. In the third 
place, the manner in which, simultaneously with Mackenzie's appear- 
ance in Berlin, the press became informed regarding matters per- 
taining to the disease of our illustrious patient. A number of 
correspondents were give audience by him, and a number of tele- 
grams to English newspapers indited, as has been ofiicially deter- 
mined. The first newspapers that used the words " cancerous " and 
" malignant growths " were English. They were in the Daily Tele- 
graph of May 24 and 25, 1887, and were based. on the Berlin corres- 
pondence of May 21 and 23. The last number begins by lauding, as 
was done on many later occasions, Mackenzie as the savior of the 
Crown Prince from the dangerous, as well as useless, operation ; while 
the following edition of the 26th announces the approaching restora- 
tion of the voice of the illustrious patient, and on the 29th is kind 
enough to excuse the fears of the German physicians on account of a 
weakness in their national character. That the British Medical lour- 
nal oiMa-Y 28, No. 1338, page 11 69, did not hesitate to mention the 
name of the disease in question, the above reference of Butlin shows 
clearly. To the German medical as well as political publications 
belongs the credit that they were not the first to speak the ominous 
name of the disease, and thus give it over to the public. The 
Berliner Tageblati, which, later, dropped every bit of consideration 
for us, at the end of May spoke only of inflammatory neoplasm of 
the vocal band. How the entranced adherents of Mackenzie in 



DR. BERGMANN'S REPORT. 25 

Germany could, at a later date, accuse Gerhardt and myself of hav- 
ing given publicity to our diagnosis, or that we, in the effort to gain 
notoriety and swell our fame, from the fact of our having made a 
correct diagnosis, had promulgated the above facts, I cannot con- 
ceive. Many of our colleagues would have acted more wisely had 
they examined carefully into the case before giving their opinions 
and conclusions to the press. 

On May 24, that is, before our joint consultation of the 25th, a 
conference took place between Dr. Wegner and Dr. Mackenzie in 
the new palace (Schloss Friedrichskron) in Potsdam, in which the 
former made careful minutes, which were accepted by Mackenzie. 
The contents are included in the Archives of the Royal Household, 
sub No. 4028. They are as follow : " Dr. Mackenzie is of the opinion 
that, considering the form of the tumor, the attempt is to be made 
to remove as much with the cutting-forceps as possible, and to 
destroy the remainder by means of the galvano-cautery. Dr. 
Mackenzie declares it as certain that, by this means, the voice will 
be restored, so that it will become loud again." In the meantime, 
mildly astringent powders were to be used on the growth. Dr. 
Mackenzie was of the further opinion that the use of the forceps was 
not absolutely indicated. He considered treatment with the galvano- 
cautery equally effective. Regarding the nature of the tumor, it was 
his opinion, based upon Virchow's examination and opinion, that it 
was a benign tumor that could be cured by intra-laryngeal treat- 
ment. 

In the minutes of the medical consultation held on May 25th, and 
taken down by Wegner, we find : " Dr. Mackenzie looks upon the 
growth, judging from its clinical history and a microscopic examina- 
tion, as an inflammatory thickening, and opines that as such it can- 
not become cancerous. If the new formation continues to grow, 
it must first be met with treatment by the forceps. If this does 
not succeed, and if other endo-laryngeal measures are not attended 
with success, the larynx must be opened." To this we added 
our opinions. Mine is almost identical with that of Gerhardt. 
According to Wegner's minutes and the Archives of the Household, 
his was as follows : 

" Although he does not believe that the tumor can be removed 
by the endo-laryngeal method, the assurance of Mackenzie that he 
can do this prompts him to acquiesce in Mackenzie's proposal, 
but only until the microscopic examination or the progress of the 
disease, that is, its recurrence, calls for another plan of procedure." 

In the report made by me at the time of this conference will be 
found : 



26 CASE OF EMPEROR FREDERICK III. 

" I expressed my fears that a long delay in the matter of extirpa- 
tion of the growth, which I certainly looked upon as epithehal can- 
cer, would allow it to assume a size that would lessen the favorable 
termination of the operation proposed. Mackenzie was opposed 
to this on the ground that the opening of the larynx would perma- 
nently injure the voice, and, if it did not destroy it, would impair it 
and make its use difficult ; while, according to his plan, the repeated 
pinching off of the tumor would, in all likelihood, preserve the 
functional integrity of the vocal band." 

Prof. Tobold submitted the following statement : 
" I consider the method proposed for the removal of the new 
growth with the cutting-forceps as ill-timed and insufficient, as it is 
impossible to remove a new growth diffused with the structures of 
the vocal bands clearly and sharply. We cannot dismiss the fear 
that a recurrence would occur sooner or later, aside from the fact that, 
from my experience, treatment with the forceps makes a rather 
rough handling of the larynx and the newly-formed growth unavoid- 
able, more especially when it presents a malignant character, thus 
stimulating the tendency to new formations, and ultimately compel- 
ling a more exact method of procedure. I consider the opening 
of the larynx to be the only proper method by which the newly- 
formed growth can be radically reached, as by this means we can, 
with certainty and absolute accuracy, cut away all diseased parts, 
and then destroy and make harmless the base with the Paquelin 
cautery. Even under these circumstances, the chances for a favor- 
able issue regarding the voice are much better than after the use of 
the forceps, which would leave an uneven, torn and mutilated vocal 
band." 

On June i, at the conference of the physicians von Lauer, Ger- 
hardt, von Bergmann, Tobold, Schrader and Wegner, we first 
learned through the physician of His Majesty, von Lauer, that the 
Crown Prince was to follow the physician whom we had consulted 
to England, and that the Emperor had acquiesced in the wishes of 
the Crown Prince, provided measures were adopted to control the 
treatmen. there through one of our local physicians. In the min- 
utes we find : " Prof. Gerhardt informs us that he has been asked 
by the chamberlain of His Imperial Majesty, Count Radolinski, 
whether he would accompany the Crown Prince. He declared his 
willingness to do so." 

What induced him at the last moment to decline Gerhardt's ser- 
vices has not been made clear. We desired his presence there, and 
begged von Eauer to mention this to His Majesty. Through Ger- 
hardt's presence I hoped to gain the assurance of the proper observ- 



DR. BERGMANN' S REPORT. 27 

ance of what had been decided upon in Mackenzie's presence 
during his second stay in Berlin : 

1. That every newly-removed specimen be sent to Virchow. 

2. That in case the tumor grew the larynx be opened. 

How far the contract was adhered to is notorious. The speci- 
men which was sent from Norwood was designated by Virchow as a 
superficial, excised fragment of mucous membrane, which would 
not justify an expression of opinion regarding the .deeper portions. 
The well-marked growth of the new formation was observed from 
week to week by Dr. Landgraf, who, for the purpose of laryngo- 
scopic examination, accompanied the illustrious patient to England 
and Scotland, as assistant "to Dr. Wegner. 

[Prof, von Bergmann's report is continued on pages 58-67, 76-86.] 



CHAPTER III. 



REPORT OF STAFF-PHYSICIAN DR. LANDGRAF. 



Prior to my departure for England in the retinue of His Imperial 
Highness, then Crown Prince of the German realm and of Prussia, 
I had gathered information from Privy Councillor Gerhardt on the 
evening of June 12 regarding the malady of His Imperial Highness, 
and also asked suggestions regarding the proper course for me to 
pursue. Privy Councillor Gerhardt refused to give me his opinion 
regarding the nature of the malady ; nor was he in position to give 
me special instructions, but referred me to Dr. Wegner, whom I was 
to accompany on the journey, and to whose instructions I was to 
hold myself subject. The last-named gentleman exacted from me a 
promise in Berlin to send no communications regarding the case 
there. In Norwood, he advised me as to the previous history of the 
case, and stated that His Imperial Highness had put himself entirely 
in the hands of Dr. Mackenzie and did not desire that we should 
take any active part in the treatment. This, therefore, restricted my 
activity to laryngoscopic examinations and to the submission of re- 
ports to my superior. 

Regarding the progress of the morbid process and points con- 
nected therewith, the patient's general condition, the matter of weight, 
enlargement of the lymphatic glands, pain in swallowing, etc., I 
could not get any satisfactory data. The results of the first exam- 
inations on June 17 and 18 have already been fully reported by Privy 
Councillor Gerhardt. 

As Dr. Mackenzie, contrary to everything observed by me, denied 
the existence of inflammation, and also denied impaired motion of 
the left vocal band, and in a hastily prepared sketch made for Dr. 
Wegner had touched neither upon the defect in the right vocal band 
nor upon the swelling at the posterior wall — as, therefore, even at this 
early stage there existed a difference of opinion, I felt satisfied that 
it would be proper that we be advised regarding the proposed thera- 
peutic measures decided upon by Mackenzie, and I made the fol- 
lowing proposal on the evening of June 19: 

An attempt should be made to obtain from His Imperial Highness 
an order to the effect that at such times that Dr. Mackenzie pro- 
posed to make any change in treatment. Dr. Wegner be informed of 



DR. LANDGRAF'S REPORT. 29 

it, and be acquainted with the reasons therefor. I further proposed 
that this should at all times be carefully entered in the minutes. This 
proposal was very promptly rejected. 

During the following days I learned that Dr. Mackenzie was em- 
ploying applications of a solution of perchloride of iron, and that 
after these applications His Imperial Highness suffered pain, which 
he was compelled to allay by the application of ice. Dr. Mackenzie 
was said to find that these applications tended to decrease the size 
of the growth. 

On June 24, I called attention to the importance of frequent ex- 
aminations, looking to the detection of glandular enlargements, and 
communicated with a person highly connected, in ' reference to the 
prognosis in case laryngotomy was performed. 

In a conversation which followed my last report, I learned that it 
was the intention of Dr. Mackenzie to again remove a small portion 
of the tumor for purposes of microscopic examination. This 
operation was done without any invitation being extended to me by 
Dr. Mackenzie, and in the presence of Dr. Wegner, June 28. I saw 
the result of this procedure on July i. The tumor had been re- 
moved. There were marked redness and swelling. The tumefaction 
at the posterior wall was more plainly visible, its surface presenting 
a grayish-yellow appearance. The enlargement was about in the 
centre, extending, perhaps, a little more to the left side. As Dr. 
Mackenzie had now corroborated, as it were, one part of my opin- 
ion, serious doubts arose in my mind regarding the exactitude of his 
method of examination, and I gave voice to this fact. In view of 
the importance of the case, I urged that Dr. Mackenzie be commu- 
nicated with, and asked whether he did not recognize the swelling at 
the posterior wall, and, if he saw it, what his interpretation of it was. 
I repeated this demand on July 2, accompanying it by a drawing of 
the case. K written answer was denied, but an oral explanation was 
promised me shortly. 

On July 4, Prof. Virchow submitted his opinion, accompanied by 
a letter couched in very hopeful terms. 

On July 8, I learned that Dr. Mackenzie had given the assurance 
that, in his estimation, the posterior wall was in a healthy state. I 
may be permitted to add here that when I had made a sketch on 
July 29, in Norris Castle, for Dr. Wolfenden, showing the location 
of the swelling. Dr. Mackenzie acknowledged its existence on 
July 31. 

On July 22, I again had the honor, in Norris Castle, to examine 
His Imperial Highness, and found that, after an interval of three 
weeks, the general redness and swelling had diminished, more par- 
ticularly at the ventricular bands. The right vocal band was still of 



30 CASE OF EMPEROR FREDERICK III. 

marked redness, but less swollen. The left vocal band showed in 
its posterior two-thirds a broad, saddle-shaped tumefaction. There 
were likewise swelling and redness at the posterior wall of the larynx, 
but no ulceration. The tumor had, therefore, reappeared at the 
site from which it had been removed on June 28. Dr. Mackenzie 
admitted this on July 23. 

On July 27, I learned that it was intended to employ the galvano- 
cautery. Prior to this, I was again permitted, on July 29, to make 
an examination. The appearances were those of the 22d, The 
motion of the vocal bands appeared to be freer. His Imperial 
Highness on this day spoke in a distinct double voice. 

On July 31, there was another examination by Dr. Mackenzie, 
followed by a long deliberation between Dr. Wegner and Dr. 
Mackenzie, when the former acquainted me with the following 
regarding the same : He had called Dr. Mackenzie's attention to 
the fact that he (Mackenzie) was the one to determine the time 
when he could proceed no further, and when it would become 
necessary to resort to extreme measures. Dr. Mackenzie had stated 
to him that he saw a process extending from the left vocal band to 
the left arytenoid cartilage (vide my report of July i), and had 
furthermore explained that there might be three possibilities that 
could lead to an unfavorable issue in the case : 

1. The least probable was the possibility of a change of the 
growth to the malignant form. 

2. We might have a case of multiple papilloma, which would then 
appear at points in the larynx other than those now affected. 

3. The case might resolve itself into one of chronic laryngitis, 
whereby the deeper tissues of the larynx would become involved. 

On Aug. 4, Her Imperial Highness, the Crown Princess, did me 
the honor to inquire of me in her loving, anxious way regarding the 
state of health of her illustrious husband. I learned on this occa- 
sion that His Imperial Highness had, since March, been a constant 
sufferer from pain in swallowing, and had only been free from this 
for a few days in Norwood. During the last few days this had 
increased, and deep respiration was also attended with pain. I did 
not hesitate to call attention to the facts which stood in causative 
relation to the first-named symptom, and dwelt upon and emphasized 
the improbability of the correctness of Dr. Mackenzie's explanation 
of the pain in swallowing, which was to the effect that an ordinary 
cold could cause it. I did not share the hope that a change of 
climate from the Isle of Wight to Scotland would have any favor- 
able effect on the disease. 

On Aug. 7, after Dr. Mackenzie had employed the galvano-cau- 
tery for a number of days, I was again permitted to make an exam- 



DR. LANDGRAF'S REPORT. 31 

ination. I found the tumor enlarged, encroaching more on the 
inferior space, and of uneven, more or less elevated surface. In 
the centre of it appeared a black spot. The tumefaction at the 
posterior part of the laryngeal wall remained unchanged. A pro- 
cess appeared to project from the lower border of the tumor to the 
swelling. The motion of the left vocal band was almost entirely- 
suspended. The right vocal band, which I found less red and 
swollen, showed clearly the afore-mentioned lesion ; it moved freely 
toward the tumor. I called attention to the fact that the almost 
total immobility of the left vocal band pointed to deeper changes. 
On this day Dr. Mackenzie admitted the existence of paresis of the 
left vocal band. 

On August 7, I took occasion, during a promenade with Dr. 
Wegner, to state to him that Dr. Mackenzie had now exhausted the 
desired eight weeks in which to restore entirely the Crown Prince to 
health, and that the fact existed that not alone had the malady not 
been favorably modified, but had grown decidedly worse. I con- 
sidered it desirable that a further consultation be held with the 
Berlin physicians, the more so as this had already been decided 
upon on a former occasion. I called attention to the dangers of 
a further delay in operating, and gave expression to my opinion 
that perhaps even now the removal of the tumor might not be 
sufficient, but that extirpation of one-half of the larynx might be- 
come necessary. 

Dr. Wegner seconded my proposition for another consultation. 
This consultation, however, did not take place. Dr. Mackenzie, I 
was informed, admitted that no improvement had taken place, but 
that all cases of cancer which he had seen presented an entirely 
different appearance ; that if it were cancer, it would of necessity 
have ulcerated before then. Up to that time, he said, he had not 
paid much attention to the motihty of the left vocal band. Per- 
haps it had been more marked previously than at present. I was 
not surprised at this admission of the superficiality of his examina- 
tions. I had on former occasions expressed my doubts as to the 
thoroughness of Dr. Mackenzie's examinations, more particularly 
when I was informed that I had the reputation of employing too 
much time in laryngoscopic examinations. 

On August 9, we took our departure for Edinburgh ; remained 
there, and later on went to Aberdeen, while His Imperial High- 
ness, to whose retinue had been added Dr. Hovell, took up his 
residence in Braemar. To this place Dr. Wegner and I were sum- 
moned on August 23, and it was here that I had the honor ot 
making my last examination of His Imperial Highness. The right 
vocal band was less reddened than formerly. The left vocal band 



32 CASE OF EMPEROR FREDERICK IIL 

moved neither during phonation nor respiration ; it was fixed at a 
point midway between the respiratory and phonatory position. The 
surface of the tumor was covered with a number of serrated eleva- 
tions that extended almost to the centre of the glottis. This 
interfered seriously with a view of the deeper portions on the left 
side, so that the process at the posterior wall was almost entirely 
hidden from view. His Imperial Highness complained of con- 
stant pain in swallowing, referring it to the left side and superior 
portions of the pharynx. 

Immediately following the examination, Dr. Hovell questioned 
me as to what I had found. He could not, he stated, notice a 
recurrence of the growth. I expressed my reg^ret not to be in 
position to give him information as to what I had seen, and 
showed surprise that he, who had so much more frequent oppor- 
tunities for examination, should question me on the subject. After 
the return from Braemar, I considered it my duty to put myself 
on record that, according to my opinion, the morbid process was 
growing progressively and steadily worse. This led to a discussion 
regarding the proper interpretation of what I had seen, in which the 
opinion was expressed that the processes extending from the growth 
were simply the remains of the old trouble which had not been 
reached by the galvano-cautery. I felt constrained to look upon 
them as new formations, and based my opinion on the fact that 
the tumor encroached much further on the glottis, and that, further- 
more, it did not show any cicatrices due to cauterization. I further 
proposed that if it were considered necessary to make another 
microscopic examination, it should be insisted on that it take place 
at once, as, with the present size of the tumor, the removal of a 
specimen would be a very easy matter. I repeated this proposal 
on August 29. On this day I was made familiar with the contents 
of the bulletin which was intended for the Reichs-Anzeiger. It 
had been prepared by Dr. Mackenzie, and it denied the recurrence 
of the growth which I had found. In the original draft of it, no 
mention had been made of the existing hoarseness. The bulletin 
was shown me, with the admonition that no further alterations in it 
would be permitted. 

Soon after this, we returned to London, and His Imperial High- 
ness dismissed us, expressing the hope that we should soon meet 
again in Berlin. Our return trip was made on September 3. 



During the time which His Imperial and Royal Highness spent in 
England and Scotland, and later in the Tyrol, those German polit- 



DR. LANDGRAF'S REPORT. 33 

ical papers, which claimed to possess reHable information, gained 
from those near to Mackenzie, announced, as well as did Mackenzie 
himself, a progressive improvement in the condition of the illustrious 
patient. More especially did the Berliner Tageblatt claim this, inti- 
mating that it received its news from a correspondent who claimed 
to have been in an ante-room of Mackenzie's at the time he per- 
formed the galvano-cautery operation, and to have accompanied him 
later in his consultation visits to Italy, finally holding the place of a 
daily visitor among the English physicians at the Casde of Charlot- 
tenburg. So reliable was this information of the different papers 
considered, that based on it they saw fit to make the most bitter at- 
tacks on the " pessimistic " stand taken by the German physicians. 
This was also the attitude assumed by the British Medical Joiirjial, 
which, on more than one occasion, gave as its informant, Mackenzie 
himself. If we compare the weekly notices of the above-named 
journal with the reports of Landgraf, we fail to comprehend how, in 
the issue of July, 1887, No. 1385, the following could appear: 

"The Crown Prince has made very marked and satisfactory progress on the 
road to complete recovery. His voice has increased in strength and resonance, 
and is almost entirely free from hoarseness. In ordinary conversation he can use 
it without becoming tired, but, as can be readily understood, cannot subject it to any 
great strain. There is still present a slight congestion of the larynx. The action 
of the vocal bands is, at present, entirely restored, with the exception of the left 
one, which shows a slight inequality at the point where the growth existed. Noth- 
ing of an extraordinary nature is at present visible except a slight elevation, cor- 
responding to the seat of the root of the small wart, and this base is, to all ap- 
pearances, in a quiescent state, showing neither signs of inflammation nor recur- 
rence. Locally, the patient's condition is such a satisfactory one that the present 
treatment is merely of a sedative nature." 

Further, the Reichs-Anzeiger also, on September 2, 1887, published 
a report sent by the physicians of the illustrious patient from Vlis- 
singen, which, by the public, was accepted and viewed almost in the 
light of a complete recovery : 

"The health of His Imperial and Royal Highness, the Crown Prince, has, of 
late, progressed favorably, his general condition being splendid. Since the last 
cauterization in July, no further increase of the tumor has taken place ; a recur- 
rence of the same is, however, not improbable. This might retard recovery, but 
should not excite any special fears. Absolute rest of the voice and avoidance of 
cold and damp air are the most important prophylactic measures to be observed in 
the near future." 

To the original draft of this bulletin by Mackenzie, Dr. Wegner 
added one sentence in his German translation, to wit: " The voice 
is still hoarse." Without this, no doubts would have existed as to a 
complete recovery at the time. If we recall that the announcement 
of the certain restoration to health came at the time of Sir Morell's 
elevation to the dignity of a baronet, we shall readily understand 
that the entire German nation expressed its admiration and venera- 



34 CASE OF EMPEROR FREDERICK III. 

tion for the English physician, and can realize that the newspapers^ 
which lauded him as the only successful physician, with correct 
judgment, had only words of reproach and condemnation for the 
German physicians. Berlin looked forward to the return of the re- 
stored Crown Prince with feelings of joy, and everywhere prepara- 
tions were made to give him a fitting reception. Then came the 
first awakening. The Crown Prince traveled, but passed Berlin by. 
His Majesty, his venerable father, waited for him in vain. 

The question arose at the time why facilities were not extended to 
those physicians who saw him during the summer, that they might 
convince themselves by personal inspection of the incorrectness of 
their views ; but any existing doubts were allayed by the fact that 
the Crown Prince had appeared in Frankfort in possession of full 
vigor and health, and that "the best informed papers" did not lack 
any number of reassuring reports. These papers also dissipated any 
fears that might have arisen from reports of continued hoarseness at 
Toblach, and of an attack of choking, which made an immediate 
change of residence to Venice necessary. In Baveno everything 
seemed to move smoothly, more especially as the press at the time 
seemed to regard the continual journeying, and the stay in a rough 
climate at high altitude, as the best proof that the German physicians 
had erred in their fears. 

The world, which had, until then, been quieted on the subject, 
was not a Httle surprised when, in the beginning of November, 1887, 
it was announced that Mackenzie had been hastily summoned from 
England to San Remo ; had declared the disease malignant, and 
insisted on having other physicians called in consultation. We can 
easily realize that this threw His Majesty, the Emperor, as well as 
the entire royal family, into a state of great excitement, and that 
His Majesty demanded authentic reports regarding his son and suc- 
cessor to the throne. To secure this. His Royal Highness, Prince 
William, was commanded to repair at once .to San Remo with the 
confidential physician, Dr. Schmidt, of Frankfort, who had been 
selected by the physicians of the Emperor. Neither Prof. Gerhardt 
nor von Bergmann was sent, as it was feared that Mackenzie would 
view their report from the standpoint of a foregone conclusion. For 
the same reason, Dr. B. Frankel was not selected, as he, although 
occupying the position of professor of laryngology, had been re- 
jected by Mackenzie in favor of Dr. Krause, who had only lately 
taken his habitat in Berlin. The Kaiser desired, as a reporter in the 
case, one totally free and unbiased. 

The particulars of the medical consultation and the conclusions 
reached, are embodied in the reports of Prof. Schrotter, of Vienna, 
and of Dr. M. Schmidt, of Frankfort-on-the-Main. 



CHAPTER IV. 



REPORT OF PROFESSOR SCHROTTER. 



When, on Nov. 6, 1887, at nine o'clock in the evening, I received 
a telegram signed by Gen, von Winterfeldt, summoning me, in the 
name of the German Crown Prince, to San Remo, I made imme- 
diate preparations, and on the morning of Nov. 7, at seven o'clock, 
took my departure. On Tuesday, the 8th, at half-past six in the 
morning, I arrived at San Remo, where I was received at the depot 
by Dr. Schrader, who conducted me to the Hotel Mediterrane, 
which was situated opposite the villa of the Crown Prince. On 
our way there I was informed that Dr. Krause, of Berlin, had also 
been called in consultation. This statement filled me with amaze- 
ment, as I expected that in a case of such great moment I should 
only be called upon to consult with physicians of known experience. 
On the other hand, I knew Dr. Krause, who had been engaged in 
his special branch of practice at my clinic in Vienna for some time, 
and recognized him as an ambitious young colleague. 

At the hotel I was greeted by Mackenzie, whom I knew well from 
former meetings, in the pleasantest manner. He apologized that he 
had been prevented by circumstances from meeting me at the depot, 
and that he would also be unable to spend the evening with me. I 
was given permission to make an examination of the illustrious patient 
the next morning alone, but stated that it would be to his best inter- 
ests if the examination were a general one, by all the attending 
physicians. 

After the arrival of Dr. Krause, on Nov. 9, in the morning, 
Morell Mackenzie, in the presence of Dr. Schrader and Dr. Hovell, 
made explanatory remarks regarding the disease and its previous 
history, and what operations had been performed, to which were 
added explanatory remarks by Dr. Hovell regarding his care of the 
patient while under his charge. It must be emphasized, as a point 
of the greatest moment in this report, that Mackenzie, when he 
again saw the Crown Prince at San Remo and reported regarding 
the changes that had taken place in the tumor, said to him : " Now 
it looks like a cancer ; " and in answer to my direct question as to 
whether he had said this, he replied in the affirmative. 



36 CASE OF EMPEROR FREDERICK III. 

Immediately following this, we all went to the villa Zirio, and 
were received by His Imperial Highness, whose general appearance 
was good, in the most friendly manner. He welcomed us with a 
voice which, though hoarse, was distinct, and I at once received 
permission to go to a darkened room and proceed with my examina- 
tion. This task was made an easy one, as the obliging patient did 
not place any obstacles in the way, but willingly and cheerfully, with 
pleasant remarks, allowed everything to be done with him that might 
be necessary for making an external as well as a laryngoscopic ex- 
amination, and this, it may be presumed, must have been distressing 
to him, as he was accustomed to Mackenzie's mode of examination, 
which differed from mine. The Crown Prince was so well informed 
as to the details of laryngoscopy that he at once remarked, at the 
examination of Dr. Krause, which followed mine : " Ah, sure 
enough, why you examine just like Dr. Schrotter ; you are a pupil 
of his." 

Although it is my habit to make careful investigation of the tho- 
racic organs, I refrained from doing so in the case, as Dr. Schrader 
assured me, in the most emphatic manner, that, from frequent ex- 
aminations which he had made, he could assure me that everything 
was absolutely normal, and that the remainder of the body showed 
nothing which could be viewed from a pathological standpoint. 

This visit was over in a short time, and we again retired to the 
salon of Mackenzie at the hotel, where the task lay before us of 
coming to a definite and unanimous conclusion. 

I had spoken only a few words regarding my opinion, when it 
became apparent that there existed decided differences. Dr. Krause 
especially emphasized the possibility of the case before us being 
other than a new formation, and possibly another ailment. I could 
find no data on which to base any such opinion. I, therefore, 
called for a division of opinions, which were to be spread on the 
minutes, saying that I could not deviate in any manner from what I 
had previously said. That I weighed carefully what I said at this 
time, goes without saying, more particularly as Dr. Schrader in- 
formed us that our opinion was to be sent to the highest personages 
in BerHn, to be there embodied in the archives of the realm. 

Dr; Krause conceded that I be allowed to dictate my opinion, 
and have it inscribed. My minutes substantiated, in the most ex- 
haustive manner, my view to the effect that the illustrious patient 
was suffering from oedema due to perichondritis, which, in its turn, 
was produced by the excursions of a malignant neoplasm (carcinoma). 

It is true that on account of the oedema it was difficult to make 
a diagnosis just then ; but, weighing carefully what I had gleaned 
from the reports of the medical press in Berlin, what Mackenzie 



DR. SCHROTTERS REPORT. 37 

and Schrader had informed me of, and, finally, what I consider 
most important, that which I had observed in spite of the oedema, 
that is, the external thickening of the larynx, the swelling, it is true 
not marked, of the lymphatic glands, and finally the laryngoscopic 
examination, I was forced to arrive at the above diagnosis. The 
oedema of the left side of the larynx revealed small projections 
extending downward from the ary-epiglottic fold, such as we fail to 
find in ordinary inflammatory tumors, and which only became visible 
when the patient's body was turned to the right and his head to the 
left, a position which he very willingly assumed. Absolute immo- 
bility of this half of the larynx, with the attendant external thicken- 
ing, could only be connected with disease of the deep structures ; 
that is, of the crico -arytenoid articulation of this side. 

If we accepted these appearances as evidence of crico-arytenoid 
perichondritis, the question would at once suggest itself, to what 
was this due ? It was just the constant recurrence and disappear- 
ance of the oedema, the long duration of the disease, and the non- 
appearance of an abscess which militated against the acceptance of 
the diagnosis of simple perichondritis. Taking into consideration 
the exclusion of every other disease, the age of the patient, the 
thickening of the larynx, more particularly the peculiar, facet-shaped 
appearance of the tumor (to which I, by the way, do not attach 
much importance), the swelhng of the lymphatic glands, it was out 
of the question to look upon the new formation as anything but 
malignant. 

I further stated that there were .only two therapeutic measures 
open to us : First, to simply wait until, owing to the increased growth 
of the neoplasm, suffocative attacks would make necessary a deep 
tracheotomy, an operation, the purpose of which would not be to 
cure the malady, but rather, while not affecting the progress of the 
disease, to prolong life. Secondly, with a view to a radical cure, to 
extirpate the larynx. This operation is again divided into partial and 
total extirpation of the organ. I had to admit my doubts at the time 
of the first examination, owing to the oedematous condition of the 
parts, as to whether extirpation of half the larynx would suffice ; 
but explained that this question could be decided during the 
operation, and stated that in all likelihood the necessity for total 
extirpation would present itself. Naturally, it would be our duty to 
acquaint our patient with the great danger which an extensive oper- 
ative interference would entail, and I suggested to him that in 
deciding upon an operation attended with such serious results, 
those high scientific authorities who had formerly attended him in 
Berlin should be consulted. 



38 CASE OF EMPEROR FREDERICK III. 

I held it to be of the greatest importance to arrive at a correct 
diagnosis, so that no time should be lost in useless therapeutic 
measures, as further delay in the matter, if the operation were 
decided upon, would not be advisable. Following this, Dr. Krause 
submitted his opinion in writing, in which he coincided with me, 
dwelling, however, upon the details of the operation, to which there 
appeared to be a tendency to opposition. 

During the afternoon we were received by Her Imperial Highness, 
the Crown Princess. Evidently she desired to hear the entire truth, 
and I had the honor to read the minutes which had been taken 
down by me. She immediately made it apparent that from this 
quarter there were decided misgivings regarding the advisability of 
an operation. In this respect, the illustrious lady was supported in 
her opinion by Dr. Hovell, whose views she desired in such a 
decided manner that I could not sufficiently express my surprise at 
it. I took the liberty, at this time, to observe that the right of 
determining what was to be done certainly belonged to the patient, 
and that even we did not consider it desirable to influence his 
determination in any way, and that from a medical standpoint we 
should have to confine ourselves to making clear to the patient the 
full facts and the chances of the different operations. 

As Her Imperial Highness opined that possibly when the acute 
oedema should have subsided in a few days, more careful examina- 
tion could be made, and I might, then, possibly modify my opinion 
regarding the disease, I postponed my departure, in accordance 
with her wishes, to Nov. ii. I protested decidedly against the 
further extirpation of additional fragments, which Mackenzie pro- 
posed for purposes of histological investigation, as such operative 
procedures could only lead to more rapid growth or to a breaking 
down of the neoplasm ; besides, there existed a doubt as to whether 
the most skilful investigator would be able to determine from an 
examination of a specimen the nature of the disease in its present 
stage. 

On the same evening. His Imperial Highness, Prince William, 
arrived, and with him, by order of His Majesty, the Emperor of 
Germany, Dr. Schmidt, of Frankfort-on-the-Main. We were all 
received by His Imperial Highness, when I again reiterated what I 
had said (as above), in the most emphatic manner. When, later, we 
had a lengthy discussion with Mackenzie, the possibilities of the 
case were once more gone over, and again differences of opinion 
cropped out regarding the diagnosis. 

On the following morning, that is, on Nov. lo, at 10:30, we again 
made an examination of His Imperial Highness, in which Dr. 
Schmidt took part. As the swelfing was a trifle less, the changes 



DR. SCHROTTERS REPORT. 39 

on the left side presented not only more characteristic appearances, 
but, to our regret, a small nodule showed itself on the right vocal 
band. This fact, had any doubt existed in ray mind, would have 
strengthened my former views ; and, in the consultation of physicians 
which followed, I declared that I could not announce any change in 
my opinion, either in regard to diagnosis or to therapeutics. Dr. 
Schmidt expressed his entire concurrence with my opinion. 

On the same day, in the morning, the opportunity had been given 
me to speak with the Crown Princess, on which occasion she firmly 
declared her opposition to extirpation, and only consented to the 
operation of tracheotomy, as, under all circumstances, she desired 
to see the hfe of her beloved spouse prolonged, and considered that 
only in this way could it be done, I then allowed myself to remark 
that it would be proper, under the circumstances, to summon to San 
Remo a German physician of experience, as the time could not be 
determined in advance when the necessity for such an operation 
should present itself. On the other hand, I considered the sojourn 
of our illustrious patient in the south as in every way indicated. I 
tlien proposed that Prof, von Bergmann be requested to hold him- 
self in readiness to go to San Remo when ordered ; but that, in the 
meanwhile, to provide against any possible contingency that might 
arise, one of his experienced assistants be sent there. To this the 
Crown Princess did not give any decided reply, as she appeared to 
believe that in Dr. Hovell she had a sufficiently competent aid. 

In the evening we were again received by His Imperial Highness, 
Prince William ; and later, in conformity to the wish of my col- 
leagues, I had written, by Dr. Krause, to whom I dictated, an ex- 
haustive memorandum regarding the chances of extirpation of the 
larynx as opposed to simple tracheotomy. This memorandum em- 
bodied the opinion of every one present, and was intended to serve 
in an explanatory way after we had made our oral communication to 
His Imperial Highness, the Crown Prince. We had resolved, when 
portraying the case to our illustrious patient, to acquaint him as 
clearly as possible with the condition of affairs ; but to temper the 
painful details, to give him the memorandum that he might carefully, 
and after thoroughly weighing everything, make his decision. 

Prior to the last examination, on the nth, in the forenoon, I once 
more had the honor of a short conversation with Her Imperial High- 
ness, the Crown Princess. The illustrious lady, filled with loving 
solicitude for the patient, begged me to make my sad communica- 
tion as gently as possible, promising me, at the time, to meet my 
suggestion regarding a German surgeon, in answer to which I*could 
not repress a word of thanks, exclaiming : " Now I return home 
feeling more calm." 



40 CASE OF EMPEROR FREDERICK III. 

As an effect of the applications of ice, which was also swallowed 
in small pieces, the oedema had partially subsided ; but the general 
appearance of the disease remained about the same, so that no rea- 
sons existed for me to change my opinion. It now became my pain- 
ful duty, for which my colleagues, in their confidence, had selected 
me, to report to His Imperial Highness regarding our investigations 
and opinions. This took place in the presence of Her Imperial 
Highness, the Crown Princess; and I must state that the whole 
scene was one of the most impressive and touching ones of my life. 

The illustrious patient, on whose countenance not a sign of excite- 
ment was visible, declined with a smile my request that he be seated, 
and received my report standing with philosophic calmness and the 
courage of a hero. When I dwelt upon the chances of both opera- 
tive methods, the pleasant expression of his face did not vary for a 
moment. Deeply impressed, I was luckily in a position to refer to 
a case which I had lately seen of an old gentleman, in whom there 
had been spontaneous and entire disappearance of a similar neoplasm 
in the larynx, and the illustrious patient seemed pleased when I stated 
to him that in this case the patient was a man in the seventies, where- 
upon he exclaimed : " Why, I am only in the fifties ! " 

After his Imperial Highness had asked the other physicians if they 
desired to add anything further to my communication, which, by the 
way, they did not, he put the question direct, but apparently without 
feeling in any way disturbed, whether the disease was cancer, to 
which I was compelled to give an answer which I qualified. One 
could not help being deeply impressed with the pleasant and hearty 
manner in which we were dismissed. No casual observer would 
have suspected that such a tragic scene had just been enacted. With 
a pressure of the hand, the noble man bid me adieu, and said : " May 
we meet again, if God so wills it." 

The Crown Princess also bid us adieu in the most gracious man- 
ner, again reiterating her approval of the plans mapped out by us. 

Dr. Schrader then handed the illustrious patient the written mem- 
orandum of the day before, regarding the chances which the different 
operations offered, and a few minutes later the will of His Imperial 
Highness was made known to us in writing, to the effect that he was 
not willing to submit to the extensive operation, but had decided to 
have tracheotomy performed. We then met at the house of Gen. 
von Winterfeldt, and in the presence of His Royal Highness, Prince 
William, the first bulletin for the Reichs-Anzeiger was indited, and a 
decision arrived at concerning further ones, which should gradually 
become graver in their tone, so that the general public might slowly 
be prepared for the gravity of the situation. It would have been 
possible, of course, as far as the public was concerned, to adhere to 



DR. SCHROTTERS REPORT. 41 

the diagnosis of perichondritis. Why the plans here laid out were 
deviated from, how it became possible that remarks made only in the 
closed circle of physicians and an hour subsequent to which I com- 
menced my journey home, were promulgated ni the most cruel man- 
ner in the newspapers, is beyond my comprehension. The later, 
constantly-recurrmg modification of the views regarding the nature 
of the ailment, as also the frequent changes in therapeutics, for the 
information regarding which the newspapers were my source, as also 
corroborative statements made to me by persons who, as I believed, 
were in a position to be well informed in the matter, were calculated, 
considering the progress of the case, to fill me with much sorrow. 

I have to add that I was commanded by Her Imperial Highness, 
the Crown Princess, to mention the true state of affairs only to His 
Majesty, the Emperor, and to the Austrian Crown Prince ; but, as far 
as the public was concerned, to observe strict silence. This order 
was revoked only a few days after my return. Then, it is true, after 
the secret was out and well-ventilated, I made a few remarks in pri- 
vate circles, and it is not my fault if these remarks were circulated in 
the most unbecoming manner. 



CHAPTER V. 



REPORT OF MEDICAL COUNCILLOR DR. MORITZ SCHMIDT. 



On Nov. TO, I found a yellowish, partially transparent oedema of 
the left ary-epiglottic fold, of such size that only the anterior two- 
thirds of the right vocal band, and only about one-fifth of the left, 
were visible. Under the latter, I observed a dark red swelling with 
a yellow covering. The entire mucous membrane of the larynx was 
of a deep red. 

On Nov. II, the oedema had in so far disappeared that I could 
see the greater portion of the left vocal band, the posterior wall, as 
well as the right vocal band in its entirety. The mucous membrane 
of the larynx was still of a deep red. Under the left vocal band, 
along its entire length, there was swelling of the sub-glottic region, 
extending beyond the margin, and dark red in color. Along nearly 
the entire length of the swelling I found an irregular, slightly-exca- 
vated yellowish portion, which I looked upon as a superficial ulcera- 
tion. The swelling in the sub-glottic region extended along the 
posterior wall to the right side, where it ended as a red nodule, 
of about the size of a large hemp- seed, at the posterior third. The 
anterior commissure was also encroached on by the swelling, which 
overlapped it toward the right. There was no motion in the left 
vocal band. I found the lymphatic gland on the ligamentum conoi- 
deum of the size of a small pea. The sub-maxillary glands on the 
left side were only slightly swollen. This might have been owing to 
other influences. 

Considering the gradual development of the trouble, extending 
over a period of ten months, and the age of the illustrious patient, 
and also the data furnished by the laryngoscope, I could not char- 
acterize the ailment as other than perichondritis owing to carcinoma. 
I desire to emphasize specially that only in carcinoma have I ob- 
served nodules such as I noticed on the right vocal band. 

The question of operative interference, as the swelling had already 
gone beyond the middle line, resolved itself into either a total ex- 
tirpation of the larynx, or a simple palliative tracheotomy. Total 
extirpation of the larynx would, at this stage, have still been possi- 



DR. MORITZ SCHMIDTS REPORT. 43 

ble, with a reasonable hope of success ; but, on account of the un- 
certain termination thereof, the physicians in attendance could not 
prevail upon His Royal Highness to submit to the operation. The 
assembled physicians had prepared a statement explanatory of the 
operations recommended, detailing its dangers and possibiUties. 
After His Imperial and Royal Highness had weighed these care- 
fully, it was his pleasure to decide against extirpation of the larynx. 
It is common practice after thoroughly instructing the patient to let 
him speak the decisive word. The communications received by me 
in Berlin from a physician who had formerly treated His Imperial 
and Royal Highness, the drawings submitted to me, as well as the 
wax model prepared by Prof. Tobold, illustrative of what he found 
in May, 1887, and which, according to the testimony of the physi- 
cians, presented a very true picture, left no doubt in my mind 
that the pathological conditions, found by me in November, were 
directly connected with those which were observed from March 
until May, 1887. 

The progress of the disease since November, its fluctuations 
and manifestations, which, it is true, I had no facihties for observ- 
ing personally, clearly corroborated the correctness of our diag- 
nosis. I have observed, in nearly every case of cancer, that there 
are periods when the disease appears to make marked progress 
toward recovery. The course which this case took, from begin- 
ning to end, appears to have been the usual and typical one. 



The declaration made by the physicians in San Remo, from 
Nov. 9 to II, is as follows : 

" After oft-repeated and searching examinations, the assembled physicians are 
entirely satisfied that in tlie case of His Imperial Highness they have to deal with 
cancer of the larynx. Regarding the treatment, its different possibilities were 
carefully weighed, and His Imperial Highness was acquainted therewith. At the 
same time, the performance of tracheotomy, when indications presented them- 
selves, was recommended. 

" MoRELL Mackenzie, 
sch rotter, 
schrader, 
Krause, 

MoRiTZ Schmidt, 
Mark Hovell." 

It is well known that His Imperial and Royal Highness, after 
receiving the report regarding the significance and chances of a 
total extirpation of the larynx, this being, then, the only operation 
which, on account of the encroachment of the trouble on the 
right side, held out any hope, expressed his decided opposition to 



44 CASE OF EMPEROR FREDERICK III. 

it, in writing, to the physicians. With great coolness and true 
heroism the illustrious patient received the communication regard- 
ing the gravity of his ailment. It even seemed to those surround- 
ing him that after the decision, which the opinion of the physi- 
cians called for, the bearing of the Crown Prince was of a quieter 
and better order ; in fact, joyful. 

Immediately following the consultation at San Remo, Dr. 
Schmidt departed for Berlin, where he arrived on Nov. 13, and, 
soon after, with the family physician, Dr. Leuthold, and Prof, von 
Bergmann, appeared before His Majesty to make his report. The 
Reichs-Anzeiger reports as follows : 

"At the examination of the larynx of His Imperial and Royal Highness, the 
Crown Prince, the physicians assembled were enabled to determine that the ail- 
ment was owing to the presence of a malignant new formation. It is situated 
mainly below the left vocal band and the posterior portion of the larynx. Slight 
traces are commencing to manifest themselves on the right side. The ailment is, 
up to date, a local one, and it has not affected the general condition of the patient. 
The danger of the new growth lies in its progressive enlargement. As His Im- 
perial and Royal Highness has not expressed his willingness to have total extir- 
pation of the larynx performed, inability to breathe will, sooner or later, deter- 
mine the necessity of tracheotomy. As the physicians assembled at San Remo 
looked upon extirpation of the larynx, even viewed in the most favorable light, as 
being of such significance in the later life of the patient that they could not come 
to the conclusion to urge the operation at all hazards, but to leave the c^uestion to 
be decided by the illustrious patient himself, it does not surprise us that the high- 
est authority again propounded the question whether it would not be proper to 
try to gain consent to operate, as otherwise the patient was surely doomed. Like- 
wise was the wish expressed by His Majesty that there should bean official report 
of the whole disease, in which it be stated clearly why the performance of the 
operation which had been planned in May and June had been abandoned, and 
why only at this late date the question of operation was again broached. For 
this purpose the minister by proxy. Count Stolberg-Wernigerode, on Nov. 13, 
called together the physicians, Prof, von Bergmann, Dr. Wegner, Prof. Gerhardt, 
Prof. Tobold, Dr. Leuthold, Dr. Schmidt, and Staff- Physician Landgraf for a 
conference in the royal ministerial chamber." 

The minutes, and everything connected therewith, which were 
compiled from the memoranda, histories and reports of all the phy- 
sicians who had seen the case, are embodied in the Archives of the 
Royal Household, and served as a basis for the report above given. 

The assembled physicians were of the same opinion as those who 
had consulted in San Remo, that is, that, at present, total extirpation 
of the larynx was indicated, partial extirpation being entirely out of 
the question. Although there were on record a number of well-authen- 
ticated cases which had been permanently cured by total extirpation 
of the larynx, still the attending physicians were of the opinion that 
before undertaking so grave an operation, the result of which might 
be fatal and would, at all events, more or less mutilate the patient, 
the wishes of the patient should be consulted and accepted as final. 



DR. MORITZ SCHMIDTS REPORT. 45 

Why the operation was not performed duruig the summer our re- 
ports plainly demonstrated: " When, in June of last year, the at- 
tending physicians had received the assurance that an operation 
would be performed as soon as the growth showed a tendency to 
enlargement, they were certainly justified in attaching the blame of 
' too late ' to that person who had overlooked the fact of enlarge- 
ment, and even denied it at the time when Dr. Landgraf called 
special attention thereto, and urgently desired a further consultation." 
The reports of Prof. Schrotter, which were read by Dr. Leuthold, 
established the fact that at any moment oedema of the ary-epiglottic 
folds might supervene, and present a condition dangerous to life and 
necessitating immediate tracheotomy. For this reason, the physi- 
cians were very decided in their demands that a surgeon thoroughly 
conversant with the operation of tracheotomy be sent to San Remo 
at once, to institute prompt operative measures in case of the much- 
dreaded complication. Dr. von Bergmann recommended, as the 
most proper person, the chief assistant of his clinic. Dr. Bramann; 
the other physicians concurred in his opinion. 



Immediately following the consultation of Nov. 9, and after the 
noble patient had been acquainted with the conclusions arrived at. 
Dr. Schrader, on Nov. 11, wrote to Prof, von Bergmann as follows: 

" I have the honor to very humbly report confidentially to your 
Well-born Highness, in conformity with the wishes of His Imperial 
Highness, the Crown Prince, and Her Imperial Highness, the Crown 
Princess, the results of the laryngoscopic investigation, and to ask 
you to kindly perform tracheotomy, which will, sooner or later, be- 
come necessary in the case, this being the expressed wish of ALL 
the physicians here present in consultation." 

Prof, von Bergmann submitted his thanks by telegraph at once, 
for the confidence bestowed upon him, following this by a letter 
later on, and declared himself ready to undertake the operation. 

But the physicians at San Remo, as also those who had been 
interviewed in Berlin on the subject, declared that at any moment 
oedema of the glottis or some other comphcation might supervene, 
interfering with the breathing-space, and that, pending the arrival 
of Prof, von Bergmann, it would be well to have a resident physician 
competent to operate if called upon. The minister, by proxy, of 
the royal house, did not feel that it would be proper to delay 
longer, but that prompt measures should at once l3e instituted, so 
that speedy assistance might be assured His Imperial Highness 
when called for. Acting on this, Dr. Bramann left Berhn by order 



46 CASE OF EMPEROR FREDERICK III. 

of His Majesty, on the evening of November i6, arriving in San 
Remo on the i8th, where he was at once informed by Drs. Krause 
and Schrader concerning the status of the case. 

It was only on November 20 that Dr. Bramann was invited by 
the physicians, who daily examined the case, to join them. Regard- 
ing this meeting, Bramann reports that by the aid of the laryngo- 
scopic mirror he discovered a marked swelling above the left vocal 
band, the band itself being either absent or so concealed by the 
swelling that it was not visible. The tumor extended from the 
left anterior commissure to the posterior wall, and then upward, 
covering almost the entire thyroid cartilage. The mucous mem- 
brane covering it was neither inflamed nor reddened, save at one 
place posteriorly, where, below the arytenoid cartilage, there ap- 
peared to be a smaller ulceration. What existed under the swelling 
of the left side could not be ascertained; the right vocal band, how- 
ever, appeared intact, its posterior portion perhaps a trifle thickened. 
During phonation it moved so freely that it appeared to hug the 
.whole region encroached on by the tumor, that is, the left ventricle, 
this accounting for the production of tone, though a weak one. 
There were no glandular enlargements either in the neighborhood of 
the larynx or the vessels. On the other hand, the left half of the 
thyroid cartilage, particularly at its posterior portion, was much 
thickened. Neither pain, cough, nor expectoration was present. 

A second examination by Bramann was made on December 9, 
and gave about the same results ; while from another source came 
the positive assertion that the tumor was growing smaller and im- 
provement taking place in the ulceration at the posterior wall. As 
at this time iodide of potassium had been given the patient, the 
improvement was attributed to the action of this remedy, which was 
credited with having "bettered and favorably modified" the "chronic 
perichondritis " (;vide communications by letter of the physician by 
proxy. Dr. Schrader, to Dr. Leuthold). As early as December 10, 
Dr. Krause, as well as Dr. Hovell, appeared to think that the 
hypersemia and swelling at the posterior wall had increased, and 
thought that they discovered a small ulceration in the neighbor- 
hood of the tumor, which was located below the ventricle. On 
December 13, Dr. Hovell reported to Mackenzie by telegraph 
regarding the above discoveries and other compHcations, the 
formation of granular tissue, etc., which was responded to by the 
arrival of Mackenzie on the 15th. 

Dr. Bramann was not invited to take part in the examinations 
and deliberations which followed on the i6th and 17th. His next 
examination was made in response to the expressed wish of the 
illustrious patient on December 23, and revealed a decided change 



DR. MORITZ SCHMIDTS REPORT. 47 

in his condition. The voice had suffered a marked increase in 
hoarseness. The swelHng of the ary-epiglottic fold was decidedly- 
larger, and even more marked was the infiltration extending down- 
ward, and showing most prominently in the region of the ventricle. 

Beyond this, neither the vocal band nor the deeper portions of 
the larynx could be seen. The swelling on the left side stood in 
close connection with the diffused infiltration of the posterior wall, 
and was only separated from it by a very shallow groove. At the 
posterior wall the swelling was not confined to the left side, but en- 
croached on the region of the right arytenoid cartilage, extending 
downward, beyond the insertion of the vocal band. A marked in- 
crease in size during the last 14 days became apparent, and an 
ulceration on a plane with the left ventricular band was plainly 
visible. From this point, the ulceration extended downward along- 
the posterior wall, past the level of the vocal band ; and it could 
not be clearly determined whether, at this point, there was an 
accumulation of secretion, or a groove filled with mucus. At 
all events, the surface appeared uneven and irregular. 

If, as has been asserted, everything was normal at the site of the 
original enlargement, the correctness of this explanation becomes 
difficult, as the deeper portions of the larynx were covered 
by the thickening of the ventricular band. It was impossible 
to see either the region of the vocal band, or those structures 
that lay below it. Judging from the extent of the ulceration 
and the swelling of the posterior wall, we were justified in 
assuming that changes were taking place, perhaps very deep 
in their extent, to which the swelling of the ventricular band 
might be secondary. The latter organ was ulcerated at its cen- 
tre, the ulceration not very prominent, nor visible in its entirety, 
this applying more particularly to its lower portion. According to 
the opinion of some of the physicians, this ulceration had, a few 
days previously, been more prominent, and had become lower and 
flatter. The report of Dr. Bramann ends with the remark that during 
the last 14 days such changes had taken place, and that probably 
before the end of the season the question of tracheotomy would 
come up. 

During the same week, the British Medical Journal (No. 1409, 
page 1455), wrote as follows : 

" It gives us great pleasure to be in a position to report, based upon information 
from an independent autliority and therefore worthy of behef, that the favorable 
accounts of the press regarding the present satisfactory state of health of the Crown 
Prince of Germany may be accepted as true." 

On Dec. 26, Sir Morell Mackenzie again appeared in San Remo. 
Immediately subsequent to his first examination, he stated to various. 



48 CASE OF EMPEROR FREDERICK III. 

gentlemen at court, as well as to the attending physicians, that he 
still doubted the presence of cancer. The enlargements, which 
had become visible two weeks before, were beginning to break down, 
and cicatrization was taking place. The good appearance of His 
Imperial Highness on Christmas eve and New Year's day again 
prompted the press to indulge in polemics regarding the diagnosis 
of cancer, more particularly the British Medical Journal, of Jan. 7 
(No. 1410, page 31): 

" It is with great satisfaction that we learn from an authentic source that the 
symptoms, which were so alarming in the beginning of November, have almost 
entirely subsided The swelling in the sub-glottic region which, at the time, was 
viewed with suspicion, has decreased in size to about one-quarter. The ulceration 
of the surface has entirely healed, and the sub-maxillary glands, which were 
swollen and hardened, are, at present, in a normal condition. The slight swelling, 
which recently appeared on the left ventricular band, has entirely disappeared, and 
the small, suppurating surface which it left had almost entirely cicatrized when Sir 
Morell Mackenzie left San Remo. The Crown Prince feels entirely relieved from 
the slight though permanent feeling of discomfort in the larynx, from which he 
had been suffering since the beginning of last year, and his face has lost that waxy 
paleness which was remarked by so many on the occasion of his last visit to Eng- 
land. We could assume from Mackenzie's opinion that the manifestations in the 
larynx of the Crown Prince were due to a rather serious chronic laryngitis. In 
support of this assumption it may be interesting to quote from the work of Mac- 
kenzie : ' In addition to congestive enlargements of the mucous membrane as well 
as sub-mucous tissue, some cases present an organized stenosis, or hypertrophy 
of the soft tissues.' He also states that we frequently find projecting growths as 
the result of chronic inflammatory action. These words were written eight yeai's 
ago, and the case of the Crown Prince appears to be a true illustration of the 
morbid condition which they describe. In addition to the inflammatory process, 
there is no doubt as to the existence of perichondritis. Sir Morell Mackenzie, 
while discoursing on this affection, calls attention to the weak action of one or both 
vocal bands (pige 391), and the case of the Crown Prince shows that activity of 
the left vocal band has been impaired since the last few months." 

At the close of the first week in January, the rumor was current 
in San Remo that the swelling, which had been heretofore confined 
to the left side, was encroaching upon the right one, and on the 
13th the Reichs-Anzeiger printed a bulletin as follows : 

"The morbid manifestations consisted, for the last two weeks, of a more 
marked swelling of the left half of the larynx, accompanied by a generally dif- 
fused and spreading irritating inflammatory condition of the laryngeal mucous 
membrane, this being accompanied by an increased mucus secretion, which, 
however, as also the inflammatory action, is fast disappearing. The general con- 
dition is quite satisfactory." 

Immediately following these manifestations, on January 14, 15 
and 16, pain in the head, elevation of temperature, difficulty in 
breathing and marked stridor appeared, until, on the 17th, the illus- 
trious patient coughed up a piece of necrotic tissue, which had for 
three days been noticed hanging loosely in the larynx. This was 



DR. MORITZ SCHMIDTS REPORT. 49 

submitted to Virchow for examination. The outcome of this inves- 
tigation was also pubhshed, but it is not generally known that the 
fragment was first given into the hands of the Warsaw physician, 
Dr. Hering, who took possession of portions of it for examination, 
so that Virchow did not receive the fragment in its entirety, but only 
the larger part thereof. 

Virchow denominated this piece as a dead and decomposed por- 
tion of the larynx, which had come from its surface and in part from 
the deeper portions, say about four millimetres. Only at one point, 
which was comparatively hard in almost every microscopic section 
made, so-called nests (bulbs) of epidermal cells, frequently homo- 
geneous, were discovered. These nests were disposed almost uni- 
formly along the surface or near it. Neither these nor well-marked 
isolated alveoli were, although carefully sought for, discovered. 
Therefore the results of this investigation were likewise interpreted 
as opposed to the diagnosis of cancer. 

But, on this occasion, the pathological anatomist was, owing to 
the bad use which had been made of his former opinions, a trifle 
more cautious, and he wrote to Krause asking him to exercise more 
discretion in his inter|jretation of the opinion furnished him. 

The medical correspondent of the British Medical Journal diid not 
take this admonition to heart, for, on Feb. 4, 1888, we find in this 
journal, (sub. No. 1414, page 257) : 

" We are enabled, through telegrams which have just been received from San 
Remo, to chronicle the joyful news, based upon the highest authority, that the 
favorable reports of the last few days can be supported. The slough, the exist- 
ence of which we mentioned some weeks ago, and which had caused so much 
alarm in November, became detached from its seat on the tumor on Jan. 17, and 
was more than two centimetres in length. The denuded surface, froiii which the 
separation of this piece of tissue had taken place, has almost entirely healed, and 
the condition of the contiguous structures is in every way satisfactory." 

On Jan. 29, Sir Morell Mackenzie again appeared in San Remo. 
On the evening of his arrival he called upon Dr. Bramann and re- 
quested him to take part in an examination the following day, re- 
marking at the time, that while there was no immediate necessity 
for tracheotomy, one could not tell what the near future would bring 
forth. When Bramann visited him on the morning of the following 
day, he remarked that the left side had improved to a marked de- 
gree, that the swelling was smaller, and that even the left vocal 
band had now become visible and was not in any way impaired in 
its integrity. On the other hand, the right side showed a more 
marked swelling than at Christmas, but this was, in his estimation, 
of an inflammatory nature. It was just this, he claimed, which would 
eventually necessitate tracheotomy, but he was in favor of resorting 



50 CASE OF EMPEROR FREDERICK III. 

to this operation only when marked difficulty in breathing super- 
vened. 

At five o'clock, in the afternoon, after the mucous membrane had 
been put under the influence of cocaine, Bramann made his first ex- 
amination. The left side, and also the posterior wall presented a 
much more strongly marked swelling than in December, so that the 
lumen of the larynx was decreased by about one-half. The diffuse 
swelling in the region of the left ventricular band ended below with 
an irregular, serrated, gray process. Beyond this, nothing could be 
seen on the left side. The enlargement was of such a nature and 
encroached to such an extent on the breathing-space, that its apex, 
during phonation, projected beyond the tense right vocal band. In 
addition to this, the diameter of the rimaglottidis was much de- 
creased antero-posteriorly. The swelling below the right vocal 
band, which extended from the left side, could only be partially 
seen. There was no doubt that the right vocal band was much more 
impaired in its motion than in December. To this circumstance it 
was owing that the voice presented an absolute want of resonance, 
and that with even great exertion a sound, such as was produced in 
December, was now impossible. Difficulty in breathing during ordi- 
nary respiration, while walking even rapidly on a level surface, did 
not exist, but showed itself only when steps were mounted, or eleva- 
tions ascended. Bramann's attention was called to this fact by the 
illustrious patient without his being questioned regarding the sub- 
ject- During conversation there was no doubt that a certain degree 
of respiratory difficulty existed. The sub-maxillary glands did not 
appear to have suffered any enlargement. On the other hand, on 
the left side, near the lower half of the thyroid cartilage, there was 
a distinct elevation, extending to the cricoid cartilage, which, in 
its turn, appeared unaffected. The tissue covering it was freely 
movable, the enlargement, diffuse, hard, not uneven, and not sen- 
sitive to the touch. The regular and progressive increase of the tu- 
mor, and the external appearance on the left side, where it was lo- 
cated, of a plainly visible swelling of the larynx prompted Bramann 
to urge upon Sir Morell Mackenzie the advisability of securing von 
Bergmann's presence, as he certainly would be ready to remain in 
San Remo for some days if tracheotomy had not already become 
necessary before his arrival. But this oroposal was then rejected, as 
well as on the following days. 



CHAPTER VI. 



REPORT OF DR. BRAMANN. 



I had, as early as January, frequently expressed my regrets to the 
attending physicians that I was not, as formerly, invited to the ex- 
aminations made in the case of His Imperial Highness, more es- 
pecially from Jan. 14 to 17, when much difficulty in breathing ex- 
isted. Under these circumstances I desired to be absolved from 
any responsibility regarding a too long delayed tracheotomy, and 
also the possibly too late arrival of Dr. von Bergmann, who had 
been designated by the highest authorities as the one who should 
operate. On Jan. 31, Mackenzie informed me that, in his opinion, 
tracheotomy would become necessary in from two to four weeks, 
and that I was to perform it. I entered a decided protest against 
this, and insisted upon the observance of the agreement made be- 
tween the highest authorities and Privy Councillor von Bergmann. 
I consented to operate only when the difficulty in breathing mani- 
fested itself suddenly, and its progress and development came with- 
out warning- In the event of a slow but progressive difficulty in 
breathing. Privy Councillor von Bergmann, was, under all circum- 
stances, to be summoned. I further called Mackenzie's attention 
to the fact that, as at the present time a slight disturbance in breath- 
ing was caused by ascending the stairs, and that its continued in- 
crease might be expected, it would be no more than proper that 1 
be permitted to see the illustrious patient at intervals of a few days, 
as Privy Councillor von Bergmann, as well as I, would only then 
operate when we became convinced from personal experience and 
investigation as to the advisability and necessity thereof. In spite 
of this, I was not allowed to see the illustrious patient again until the 
day of the operation. 

From those in attendance I learned, during the following days, 
that the color of the Crown Prince's face underwent frequent changes, 
and that breathing, more especially when the stairway was ascended, 
was attended with difficulty. On February 3 and 5, during the after- 
noon, I interviewed Dr. Schrader regarding the above observations, 
and he verified their correctness. I interrogated him whether it had 



52 CASE OF EMPEROR FREDERICK III. 

still not been decided to call me in, and whether in the face of the 
slight though constantly-present trouble in breathing it would not be 
advisable to summon Dr. von Bergmann. Dr. Schrader shared my 
opinion, and desired to do everything in his power in the matter, but 
begged me not to urge him, but to wait patiently, as he hoped to be 
able to arrange a consultation with me in the near future. 

On Sunday, Feb. 5, Dr. Schrader and his aids reported to me that 
the breathing-sounds had increased to such an extent that at table 
nearly every respiration of the Crown Prince could be heard at the 
other end of the board. While ascending the easy steps of the villa 
he was compelled to make several pauses. When out driving it is 
true he left the carriage, but only to walk short distances. Aside 
from the difficulty in breathing, he complained of marked lassitude 
and weakness of the limbs. 

On Monday the 6th, in the morning, the same gentleman reported 
to me that the difficulty in breathing had increased, and on the morn- 
ing of Feb. 6, I telegraphed to Privy Councillor von Bergmann : 
" Stridor during quiet respiration. Hold yourself in readiness to de- 
part at once," Krause, likewise, corroborated the presence of stridor 
and difficulty in breathing, which was to be referred to the increase 
of the swelling on the right side. In answer to my question if it 
would not be correct and, in fact, necessary, to summon von Berg- 
mann at once, he replied that Mackenzie would arrive on the morrow 
and then it would be determined. An extended conversation then 
ensued regarding the diagnosis of the illness, in which Krause ex- 
pressed himself as leaning to the diagnosis of perichondritis, sup- 
porting his opinion with the statement that the separation of necrotic 
fragments had not been observed in carcinoma ! 

On Feb. 7, I learned from Schrader that the last night had been 
a rather bad one, and that Mackenzie had acknowledged the marked 
increase in the swelhng. Although Schrader now strongly urged 
that von Bergmann be present, this was not heeded, neither did I 
receive any invitation to be present at the next consultations. It is 
a remarkable circumstance that on this day, that is, Feb. 7, the Voss- 
ische Zeitung published in Berhn, as is alleged from English sources, 
that tracheotomy was to be performed on the following Thursday, 
Feb. 9. 

Truth wrote on Feb. 9 : " The papers are misinformed when they 
assert that this important operation is to be performed by Dr. Bra- 
mann. It is true that this young man has been planted in San Remo 
for this and for no other purpose. Notwithstanding, I have the best 
reasons for believing that when tracheotomy does become necessary, 
an Enghsh hand will perform it, and an EngUsh head determine its 
necessity." 



DR. BRAMANN'S REPORT. 53 

Early on Wednesday, Feb. 8, I learned from Schrader that the 
night had been disturbed by headache and by stridor, which was 
more marked ; that Mackenzie would request me to be present 
at the consultation of Thursday morning, and that then it would 
be determined whether the services of von Bergmann, which I con- 
stantly demanded, be called into requisition. On Wednesday after- 
noon I sought Mackenzie, because the attendants had reported very 
difficult breathing, and questioned him as to whether this difficulty 
was very marked and the necessity for tracheotomy imminent, as then 
it would be better to err on the side of safety and telegraph to von 
Bergmann too early rather than too late. His response was that, 
according to his opinion, there were still 8 to 10 days' time. 

On the evening of the same day, at half-past nine o'clock, his 
attendants expressed themselves to me as much alarmed regarding 
the difficult breathing ; that during conversation held by the Crown 
Prince, after his meal, with an officer from a Schleswig regiment, he 
suffered a very serious attack accompanied by such a fear-inspiring, 
whistling respiratory sound that all present turned toward him greatly 
alarmed. When he left the salon to repair to the examining-room, 
he asked the question : " Has Dr. Bramann been requested to 
attend this evening ? " to which he received a response in the nega- 
tive. At the consultation of Thursday, Feb. 9, I noticed, as soon 
as the Crown Prince entered, that with every respiration there was 
marked difficulty in breathing, and stridor. He spoke with great 
effort. The illustrious patient appeared to be much affected and 
much paler than heretofore. In response to my question how he 
had spent the night, he answered: "Not comfortably, but better 
than the preceding nights." He had had a few attacks of violent 
coughing with expectoration. The sputa, which had been preserved 
by the attendant in a vessel half filled with water, was tinged with 
blood. 

At the laryngoscopic examination, during which difficult breathing 
was specially marked, showing an extensive respiratory obstruction 
during inspiration as well as expiration, the left half of the larynx, 
as well as the left ary-epiglottic fold, appeared much infiltrated, as 
also did the entire posterior wall of the larynx. More especially 
was this true of the region of the ventricular band, which was much 
tumefied, and extended to the right beyond the middle line. The 
right vocal band was motionless ; below it, especially toward the 
anterior half, a pale tumor was visible, covered with mucous mem- 
brane and extending toward the left side, where it was lost in the 
general swelling. The rimaglottidis was no longer present, and the 
entrance of air only possible because of the different elevations at 
which the enlargements lay on both sides. 



54 CASE OF EMPEROR FREDERICK III. 

After we had all made our examinations, and I had likewise ex- 
amined the larynx externally by palpation, on which occasion the 
swelling of the left side of the cartilage, to which I had formerly 
called attention, as well as the thickening of the entire lower portion 
cf that half of the larynx, showed prominently, we repaired to the 
residence of Mackenzie. On our arrival there, Mackenzie announced 
without further comment : " The difficulty in breathing has suffered 
a marked increase since yesterday evening and has reached a degree 
when further delay is not permissible," and that he favored immedi- 
ate tracheotomy. This was concurred in by Krause and Hovell. 

I admitted that the fact of difficult breathing was a natural con- 
sequence of the rapid growth of the tumor, but reverted to my 
former and oft-repeated declarations that I should not operate until 
I had personally determined its necessity from actual observation. 
As I had only seen the illustrious patient during the short time 
consumed at the general consultations, and as, therefore, I was not 
in position to know whether the difficulty in breathing was at all 
times so distressing, or was perhaps only a result of the excitement 
and exertion dependent on the examination, I could not decide to 
operate at once, but demanded a postponement of some hours, during 
which I desired to have all facilities extended me to observe the 
illustrious patient closely, and I also insisted upon summoning 
Privy Councillor von Bergmann immediately. In this I was warmly 
supported by Dr. Schrader. In response to this, Sir Morell Mac- 
kenzie declared that he would, in case I did not operate, be con- 
strained to drop all responsibiUty. Krause and Hovell supported 
him in this. I persisted in demanding an extension of a few hours, 
more particularly as I had firmly decided that in case of ameliora- 
tion of the symptoms I should wait until the arrival of Privy 
Councillor von Bergmann, as tracheotomy under the existing cir- 
cumstances was not to be looked upon as an indifferent or simple 
procedure.* To this the remaining gentlemen assented. 

In the meanwhile, compresses of ice about the neck, and appli- 
cations of cocaine were to be employed. Mackenzie undertook the 
task of seeing that these measures were properly carried out, and 
promised likewise to secure for me immediate permission to observe 
the Crown Prince. A report was then formulated which read as 
follows : 

* In the monograph on tracheotomy, in BiUroth-Luecke's Encyclopsedia, we find : " In the whole 
doctrine of the operative technique of tracheotomy there is no worse nor more dangerous heresy 
than the belief that the operation is easily performed on a suffocating patient Bad text and refer- 
ence-books on surgery have done much to spread this belief, based, perhaps, upon the experiences of 
one or two operations, or dependent entirely upon the productions of the pen." In another place, 
Billroth is even more emphatic, and confesses that there is no operation which he regards with more 
fear than tracheotomy under the above circumstances. I trust that this may serve for the enlighten- 
ment of those who spoke and wrote of my operation as a small and insignificant procedure. 



DR. BRAMANN'S REPORT. 55 

"The difficult breathing which has existed during the last few days has in- 
creased, owing to the swelling on the right side, to such an extent that prompt 
tracheotomy appears to be called for in case improvement does not supervene 
within the next few hours." 

I signed this bulletin, adding that my signature was to be applied 
only to its last portion ; that is, that tracheotomy would become 
necessary if, etc. I could say nothing regarding the increase of the 
progressive difficulty in breathing to its present point, as I had not 
been called to a consultation since January 30, nor seen the illustri- 
ous patient since that time. 

It was only at 12:30 o'clock that Mackenzie sought me and 
stated : " The Crown Prince expects you at one o'clock, and I feel 
it incumbent on me to again inform you that I must decline to take 
any further responsibility in the matter, and that henceforth you 
must assume it alone." At one o'clock I repaired to the sleeping 
apartment of His Imperial Highness, where I was received by him 
at once. The difficulty in breathing was more marked than in the 
morning, stridor more prominent during each inspiration, retraction 
of the scrobiculus cordis and episternal space, the lips pale, faintly 
blue, the voice without resonance, and speech accomplis led only 
with the greatest difficulty. In addition, I learned the following 
from the illustrious patient : The preceding four nights, but more 
especially the last one, had been bad, terrible. Only by building 
up a number of pillows and assuming a sitting posture had he been 
enabled, though with frequent interruptions, to sleep a few hours. 
On the least exertion which he had made in bed, as, for instance, 
turning to one side, drawing out his handkerchief, etc., respiration 
had become especially difficult, and at such moments a feeling of 
fear and anxiety had taken possession of him. 

The gentleman of the privy chamber, who had spent the last two 
nights near his illustrious master, related to me, without being ques- 
tioned, what he had observed. The illustrious patient who, until 
recently, had rested in a horizontal position, could, according to my 
informant, for the last six days, only obtain rest when his head was 
much elevated ; that is, when he assumed a sitting posture. Res- 
piration was quite loud from time to time, of a snoring character, 
and every hour, or even oftener, there were moments when the illus- 
trious patient did not seem to get any air, when he suddenly awoke 
coughing violently. On the night from the 7th to the 8th the Crown 
Prince had risen from his bed and gone to his room, saying : " I 
can endure this no longer; I wish you to make cold applications to 
my neck." The easy stairway leading to the first floor could not be 
ascended by the patient for the last few days without assistance ; 
this was confirmed by the statement of His Highness in person. 



^6 CASE OF EMPEROR FREDERICK III. 

In the face of these data, which had been verified by me, and the 
increase of difficuUy in breathing, the possibihty of further postpone- 
ment seemed to me very remote ; more particularly, a delay of 
two days, until the arrival of Privy Councillor von Bergmann. I 
communicated accordingly with His Imperial Highness, informing 
him that I considered it hazardous to postpone the operation, and 
advised its immediate performance. To this he readily assented. 

I at once proreeded, with Dr. Schrader, to make preparations for 
the operation, and cast about to find a table suited to the purpose. 
I regret that my wish to be allowed to operate on a table was not 
gratified. I was compelled to make use of a very wide bed for the 
purpose. 

When everything was in readiness for the operation, new compli 
cations arose regarding the matter of chloroform narcosis, which 
was vigorously opposed by Sir Morell Mackenzie, on the ground 
that tracheotomy, during the anaesthesia produced by chloroform, 
became a very dangerous procedure, and that therefore in England 
the operation was performed without it. To this I responded that I 
had in every case, up to date (and I had performed tracheotomy over 
400 times on children and adults), employed chloroform ; that the 
use of chloroform in Germany was general, and that in the case 
before us, especially as it was burdened with great responsibilities, I 
was not ready to operate under other conditions than those which 
I considered correct and proper and to which I was accustomed. 
As I still persisted in my opinion, in spite of all opposition, and was 
strongly seconded by Dr. Schrader, Sir Morell Mackenzie finally 
acquiesced ; but only after again mentioning that he desired to be 
relieved from all responsibility regarding what might occur as a 
result of the narcosis. The illustrious patient declared himself, in 
response to the request of Schrader and myself, as ready for the 
narcosis. 

In the beginning of the narcosis, which was brought on gradually 
and very carefully, frequent intermissions in breathing were manifest, 
the respiratory sounds (stridor) were very high in pitch, and the 
retraction of the episternal space and scrobiculus cordis quite 
marked, a circumstance which I demonstrated to the physicians 
present. In a comparatively short time, during which there was no 
stage of excitement, insensibility took place. I now entrusted Dr. 
Krause with the control of the narcotic. Dr. Schrader assisting me 
at the seat of the operation, Mackenzie controlling the pulse on the 
left side, and Dr. Hovell at hand with two basins of sponges and 
artery forceps. After placing a hard bolster under the shoulders, I 
endeavored to place the head in a lower position. This I was only 
enabled to accomplish in part, for as soon as the head became lower 



DR. BRAMANN'S REPORT. 57 

difficulty of breathing supervened, so that I was compelled to con- 
tent myself with an almost horizontal position. In this case it was 
so much more trying, as the larynx was very deeply situated, the 
cricoid cartilage almost reaching the episternal space, and the mus- 
cular elements of the neck strongly developed. After thoroughly 
disinfecting the seat of the operation and shaving the parts up to 
the seat of the hyoid bone and removing the points of the beard, I 
proceeded to operate, during the performance of which I personally 
took from the table at my left my instruments, ligatures and other 
materials required for the operation. With an incision 6 centimetres 
in length, and extending from the cricoid cartilage to the episternal 
notch, I divided the skin and fascige and entered, after carefully 
arresting the hemorrhage, and keeping well in the median line, 
between the space left by the two strongly-projecting sterno-hyoid 
muscles, to the fasciae covering the thyroid cartilage. The latter was 
covered by a number of strongly-dilated veins, and was situated 
rather deeply. In view of the difficulties that accompany the laying 
bare of the trachea, in such cases, below the isthmus, and above all, 
considering the danger of hemorrhage from the over-distended ves- 
sels which, even with the greatest care, cannot always be preserved 
in their integrity, and requiring for the exercise of care more assist- 
ance than stood at my command, I decided to perform Bose's 
operation, and divided, after carefully using double ligatures, the 
vessels situated at both sides of the isthmus. I was now enabled to 
crowd the thyroid cartilage down sufficiently so that the trachea lay 
exposed as far as the fifth ring. At this moment a faintness appeared 
to have seized the patient; his face became pale, pupils dilated, the 
pulse small and slow, but this condition rapidly subsided. I now 
proceeded, after thoroughly arresting the hemorrhage, to open the 
trachea from the third to the fifth ring, exactly in the median line, 
and after I had become convinced from careful inspection that it 
contained nothing abnormal that could be seen through the incision, 
and that no trace of the obstruction above was visible, I introduced 
a large silver canula, with movable shield, having a lumen of 11 
millimetres, and then tamponed the deep wound around the canula 
with iodoform gauze, covering the whole with a plain bandage. The 
time consumed in operating, mcluding narcosis, was 20 minutes. 

After the dressing had been completed, the illustrious patient 
awoke, vomited, after which he felt easier and repeatedly expressed 
his gratification to me, as well as to the assembled physicians, at the 
ease with which he could now breathe. 



CHAPTER VII. 



DR. VON BERGMANN's REPORT. — Continued. 



Immediately following the operation, and by direction of the 
highest authorities, the family physician by proxy, Dr. Schrader, 
telegraphed to Prof, von Bergmann that, although tracheotomy 
had been successfully performed, he should repair thither at 
once. Marshal Major von I.ynker telegraphed to the same effect : 
" Their Imperial Highnesses have requested that you repair to this 
place without delay." A third telegram of a like tenor was deliv- 
ered too late, that is, several hours after his departure. The tele- 
gram which had left San Remo at lo o'clock in the morning, sum- 
moning Prof, von Bergmann, was in his hands since two o'clock. 
At this time the Emperor, who had been informed of the necessity 
of immediate tracheotomy, received him and questioned him re- 
garding the results and effects of the operation, commanding Prof, 
von Bergmann, at the time, to remain in attendance on the illus- 
trious patient until the wound had healed and surgical attendance 
became no longer necessary. After His Majesty was in receipt of 
the information that the operation had been successfully performed, 
he again graciously deigned to leceive the professor, and instructed 
him to depart as quickly as possible, to send regular reports, and to 
use his best endeavors, that is, if the condition of the illustrious pa- 
tient allowed it, to arrange for his return to Berlin. 

Prof, von Bergmann took his departure, in company with the 
chief marshal of the Prince's household, Count von Radolinski, and 
arrived in San Remo on Feb. it. A few minutes after his arrival 
he saw the illustrious patient, who impressed him most favorably. 
His Highness looked fresh and strong, was elastic in his move- 
ments, and expressed his satisfaction not alone with the favorable 
termination of the operation, but with the prompt appearance of the 
professor. 

The further report of Privy Councillor von Bergmann, is as fol- 
lows : 

The first few day< following the operation were favorable for the 
illustrious patient. The dressings below and surrounding the canula 
were dry, not covered with blood, nor any other products. There 



DR. BERGMANN'S REPORT. 59 

was no fever, and the respirations ranged between 16 and 22. On 
the morning of the 12th we changed the canula. I convinced my- 
self, after the removal of the pieces of iodoform gauze with which 
the wound was packed, that its appearance was entirely satisfactory. 
It was in every way correct, lay exactly in the middle line, was free 
from accumulations of blood, and inflammatory appearances. It is 
my wont not to allow the first canula to remain in place too long. 
The construction of the canula used by me prevents, by virtue of its 
curve and its connection with the shield, all chances of pressure on 
the walls of the trachea. The shield is freely movable with both 
tubes, and in all directions, so as to allow changes in the position of 
the canula horizontally as well as vertically. The curve of the canula 
at its upper two-thirds equals about the sixth of a circle having a ra- 
dius of 5 centimetres; the lower part is straight in line m the direc- 
tion of the tangent of this circle. It is evident that under these cir- 
cumstances pressure could be possible, if at all, on the anterior tra- 
cheal wall only. This could, on account of the movable connection 
of the canula to the plate attached to the neck, only take place when 
the patient leaned well forward. In a standing, but more particu- 
larly in a lying posture, the anterior tracheal wall must, of necessity, 
be free. In spite of this, I substitute another canula after a few 
days, sometimes employing a thicker one, sometimes one less curved, 
and then either a longer or a shorter one. In making these changes 
I keep in view the peculiar formation of the parts, and thus con- 
stantly change the points of contact. We had taken with us 18 sil- 
ver and rubber canulse of different curves. From among these Bra- 
mann had selected those best suited to the requirements of the case. 
The newly introduced canula differed from the previous one in that 
it measured 9 centimetres in length, that is, it was half a centimetre 
shorter, and a trifle less curved. 

On Feb. 12 and 13, we remarked that during the paroxysms of 
coughing, which occurred about every three hours, a tenacious, 
brown-colored mucus appeared, which was also found when the 
inner canula was cleansed, containing small, dark and soft bloody 
coagulae, about the size of a hemp-seed, as also an admixture of 
streaks and small drops of fresh blood. This expectoration had an 
offensive odor. According to the statement of the gentleman of the 
privy chamber, the expectorated matter of the week before the 
operation, although rare, presented like characteristics. 

On the morning of the 14th the cough of the illustrious patient 
having, during the night, increased, as also the expectoration, Mac- 
kenzie insisted, at the consultations which took place at 9 o'clock in 
the morning and evening, that the presence of blood had its origin 
in an injury done the posterior wall of the trachea by the canula. 



6o CASE OF EMPEROR FREDERICK TIL 

I demonstrated the construction of the canula used by us, to show 
him how contact of the same with the posterior tracheal wall became 
impossible, separated the edges of the wound with two blunt hooks 
and begged him to satisfy himself by sunlight of the integrity, even 
marked paleness, of the tracheal mucous membrane at the suspected 
point. As the pieces of iodoform gauze at the lower angle of the 
wound did not show a trace of blood, hemorrhage from granulated 
tissue could be excluded. According to my opinion, the explana- 
tion was that material flowed downward from the larynx, as we could 
no longer doubt that since Jan. 17 (when a large necrotic fragment 
was coughed up, and at that time fever and headache had shown 
themselves) there had been ulcerative breaking down of the carci- 
noma. In support of my opinion, there were the soft consistency 
and offensive odor of the matter coughed up, as well as the circum- 
stance that at that portion of the convexity of the canula which 
pointed toward the larynx, a black spot of sulphide of silver had 
manifested itself. This point would necessarily be most exposed, 
being nearest the larynx, to the influence of the products in process 
of decomposition. Mackenzie did not agree with us, but adhered 
to his opinion, and requested me to employ his modification of the 
Durham canula. A specimen which he showed, he himself declared 
as useless in the case, as its calibre was insufiicient, the tenacious 
nature and large quantity of the mucus calling for a wider tube. 

I assumed that our difi'erences regarding the origin of the blood 
and the points pertaining to the expectoration would he kept secret 
until a mutually satisfactory explanation had been arrived at, but in 
this respect I was disappointed, because I learned at noon, on the 
same day, that Mackenzie had informed Her Imperial Highness that 
the more frequent cough and brown expectoration resulted from an 
injury done the tracheal mucous membrane by my employment of a 
canula unsuited to the case. In the evening, Hovell submitted to 
the home council two drawings, one of which was to serve as an 
illustration of the point of pressure which my canula exercised, the 
other one the more rational position of the one proposed by Mac- 
kenzie. On the following day was found in the Vienna and Berlin 
papers, which were controlled by the correspondents of Mackenzie : * 

"San Remo, Feb. 15, 10:45 ^- '^^ 
" The bloody coloration of the mucus, which has manifested 
itself during the last few days, is due, we take it, to injury done by 
the canula." 

*The corresjiondent in question announced, through an extra edition on Feb 19, in Berlin : " Cer- 
tainly.'' said Sir Morell Mackenzie to me. "you, as well as the reading public, have had sufficient op- 
portunity during the last 8 months to verify the truth and correctness of the announcements of the 
Tageblatt regarding the progress of the Crown Prinze's case, and to believe in their authenticity. 
He authorized no one to question the trustworthiness of my statements." 



DR. BERGMANN'S REPORT. 6i 

I had upbraided Mackenzie for giving publicity to this fact. He 
did not deny that he had given the information to the corres- 
pondents, and wrote to me, this time in French : 

" Le correspondant de ces deux journaux qui a etudie la matiere 
de la tracheotomie au fond, croyant peutetre pacifier les esprits agites 
en AUemagne en s'exprimant d'une maniere circonspecte en disant 
sur ce sujet : * 

" Slight hemorrhages are not rare in such cases. Perhaps the 
canula does not fit, and will be replaced by another." 

As in this case, so in nearly all the general medical resolutions, 
our work was made more difficult ; as even before the subject under 
consideration had been finally settled by the physicians, before even 
it had been broached, the family of the illustrious patient, as well as 
he, were informed of the published opinion of Mackenzie, based 
upon his plausible explanations and reference to his past experience. 
No less did the general management of the case suffer, although 
Mackenzie left the entire treatment of the wound to Bramann and 
myself, through his unwillingness to acknowledge that we were the 
ones to decide as to what measures were to be adopted in the 
management of the case. We learned from him, at the consultation 
on the morning of Feb. 17, that on the evening previous he had 
made a laryngoscopic examination, and had satisfied himself as to 
the absence of any trace of blood in the larynx. Shortly after, the 
above-mentioned Berlin newspapers reported that at this examination 
Mackenzie had observed that when the canula which the Crown 
Prince wore was closed, the voice appeared to be better than prior 
to the operation. I upbraided my colleague in the most unequivocal 
manner, and asked him firmly to desist from any further one-sided 
examination, but only to take part when the other physicians, who 
had been appointed by the highest authorities, were also present. 
According to my opinion regarding the source of the mucus and 
blood, I felt constrained for the present at least, to forbid any forci- 
ble expiratory efforts on the part of the patient, as I considered them 
decidedly harmful. Only by observing absolute rest might it become 
possible to prevent further disintegration of the tissues of the larynx. 
Notwithstanding this, Mackenzie insisted that the larynx of the illus- 
trious patient was to be the objective point of his activity solely. 
This sentiment received its sharpest expression at a latter consul- 
tation with Prof. Kussmaul, to which he submitted, as it appeared, 
very readily. He wrote at the time : " I only asked consent for Prof. 
Kussmaul to make an examination of the lungs. * * * j ^m 

* " The correspondent of these two papers, who has thoroughly studied the subject of tracheotomy, 
thinking, perhaps, to quiet the agitation existing in Germany by expressing himself temperately, in 
speaking of the matter, said : " 



62 CASE OF EMPEROR FREDERICK III. 

ready to admit that Prof. Kussmaul may be a better auscultator than 
I am, I shall be glad to learn his opinion as to the state of the 
lungs, but I cannot admit that he is a laryngoscopist of the same 
standing as myself." 

This was the cause of his remaining absent from the case after 
Kussmaul's first visit. It required repeated explanations, and the 
gracious interference of Her Imperial Highness, the Crown Princess, 
to gain from Mackenzie consent to what had been heretofore the 
unquestioned privilege of every physician consulted ; that is, the 
thorough and entire examination of the patient. At the second 
visit of Kussmaul, he made his appearance and assisted at the 
laryngoscopic examination. We had at the time, in consultation, 
agreed that on account of an inter-current diarrhoea, a few drops of 
tincture of opium were to be given. Shortly after, when I entered 
the sick room I noticed that the attendant gave the illustrious patient 
a tablespoonful of another mixture (a solution of haematoxylin). In 
response to my question why opium was not being given, I learned 
that Dr. Mackenzie had otherwise ordered. Not even in this in- 
stance did our colleague appear to consider himself bound by the 
general resolutions of the medical council. 

The quantity of expectorated matter underwent marked variations. 
Sometimes from four to six hours passed, particularly during the 
forenoon, during which the patient did not cough. Then, however, 
there came violent attacks of coughing, lasting, at times, several 
minutes, during which from one to two cubic centimetres of pus and 
ichor were projected into the compress, sometimes filling the inner 
canula to such an extent that an immediate change for another 
became necessary. On Feb. 15, we had collected a sufficient quan- 
tity of this material to enable us to utilize it for purposes of micro- 
scopic investigation. We found under the microscope, in addition 
to pus and blood corpuscles, numerous globular bodies, which were 
unmistakably concentrically disposed epithelial cells, and close to 
these, small processes which consisted of closely packed, large, pave- 
ment epithelium. In a few preparations we found, in addition, 
many elastic fibres. 

On J'eb. 12, Dr. Mackenzie had written, in No. 8 oi the Berliner 
klinische Wochenschrift : "According to my opinion, the clinical 
symptoms are at all times fully in accord with the diagnosis of a 
benign growth, and the microscopic examination is in accord with 
this opinion," and also : " At this moment, medical knowledge does 
not permit me to say that any diseases are present other than a 
chronic inflammation of the larynx, combined with perichondritis." 
Before the type-setter in Berlin had printed these words, the most 
important and scientific proof in refutation of this opinion of Mac- 



DR. BERGMANN'S REPORT. 6^^ 

kenzie was given by the same surgeon whose accurate clinical 
diagnosis, during the preceding summer, had been so long questioned. 

On Feb. i6, when we were in possession of a satisfactory num- 
ber of typical preparations, I first invited Dr. Krause, and through 
him the two English colleagues, to satisfy themselves as to the results 
of our microscopic investigations. Krause declared himself, when 
he learned that an opinion of a different nature was in preparation, 
as fully convinced. Mackenzie, however, acquainted us through 
him that he did not consider himself competent to judge of micro 
scopic questions, as in England it was considered proper, in such 
matters, to allow the anatomist alone to speak. 

We did not require an anatomist. We were now in possession of 
that proof of the malignancy of the laryngeal ailment, which Mac- 
kenzie alone still seemed to desire ; that is, the anatomical one. 
Between the bundles of elastic fibres and between muscular fibrilli, 
we saw carcinomatous deposits, showing that they had their origin 
in the deeper portions and not on the surface. The development 
and history, as well as the clinical manifestations of the new forma- 
tion, coupled with the certainty that everything else which might 
possibly produce similar manifestations and might be confounded 
with laryngeal cancer could be excluded, were sufficient proof to 
us as to the correctness of our diagnosis. We had never been 
quite able to comprehend the point of view from which a physician 
would make his diagnosis, and base his treatment, only when it had 
been verified by the knife of the anatomist — a point of view which, 
pushed to the furthest limit, would bring the physician to the post- 
mortem table. But even this excentric demand had been met. 
Every day furnished us with new preparations, and every day 
brought us two verifications : 

1 . The diagnosis of cancer ; and 

2. The fact of the breaking down of the new formation. 

The longer this continued, the more necrosed tissue adhered to 
the coagulse contained in the expectoration, and the more numerous 
became the elastic fibres and muscular fragments. At last, on the 
24th and 28th, plainly visible pieces of cartilage became apparent. 
But Mackenzie still insisted that my canula produced all these dis- 
turbances. He complained to the exalted relatives of the patient 
that I opposed him, and designated the use of my canula (which did 
not communicate with the upper larynx) as an obstacle to the further 
treatment of the laryngeal affection. As soon as he should be per- 
mitted to introduce his apparatus, all the threatening manifestations, 
more particularly the presence of blood, would depart. Only then 
could use be made of insufflations and the application of other 



64 CASE OF EMPEROR FREDERICK III. 

remedies in the larynx. At the laryngoscopic investigations, which 
I made m the third week following the operation, and at which 
Mackenzie was present as were also the other physicians, the entrance 
to the larynx revealed two thick, arrow-shaped masses, which 
obstructed it almost entirely, so that when the canula was closed 
with the finger, during an expiratory effort, hardly a breath of air 
could force its way through the narrow slit that remained. This 
caused the aphonia of the illustrious patient. This also accounted 
for the fact that pus and cancerous ichor were not discharged byway 
of the mouth, but flowed, of necessity, into the trachea and against 
the canula. Under these circumstances and, as in the meanwhile a 
proper canula of the size of 12 millimetres had arrived from London, 
I proposed to Mackenzie to give it a trial. On the evening of 
February 20 it was introduced. It differed from the one formerly 
used, in that it was bent at right angles and consisted of a rigid, 
horizontal and articulated vertical portion. By means of a screw 
the horizontal part could be lengthened or shortened. 

The night following its introduction was better than the previous 
one. The bloody matter which was coughed up became less and 
less. This serves to explain that on the morning of the 21st the 
newspapers, whose correspondents, as has been officially determined, 
were, immediately following the morning consultations, received by 
Mackenzie in the Hotel Victoria, telegraphed to all sides: "The 
irritation to cough and bloody expectoration has ceased since the 
introduction of Mackenzie's canula." 

The Standard, which on the previous day had written, "The con- 
dition of the larynx is satisfactory, but that of the trachea serious, 
thanks to the errors of the German surgeons in the selection of the 
canula and the treatment of the wound," now announced 
triumphantly : 

" Sir Morell, as soon as he saw the canula, expressed his disapproval at once, 
and warned the physicians against its introduction, as it was calculated to irritate 
the larynx of the Crown Prince. As a matter of course, they adhered to their 
opinion and would not be advised. The canula was introduced. After a day or 
two transpired what Sir Morell had prophesied. The Prince coughed up mucus 
mixed with blood, because the lower end of the canula had broken through the 
mucous membrane with which it had come in contact. This state of affairs lasted 
from Thursday the 9th until Monday the 20th. During all these long days the 
Prince coughed, and this cough was so annoying, particularly during the night, 
and his sleep was so disturbed, that even the Germans began seriously to question 
their wisdom. On the same evening, the German physicians submitted, removed 
their canula and permitted Sir Morell to introduce one of his own. This is the 
second phase of the case, and what was the result? That night brought refresh- 
ing sleep. This the German physicians were compelled to admit in their bulletin." 

On Feb. 25, the British Medical Joiirfial ioWowed suit. It stated : 



DR. BERGMANN'S REPORT. 65 

" The Crown Prince is commencing to make satisfactory progress. The cause 
of the untoward local symptoms was owing entirely to things mechanical. The 
canula first introduced in the trachea did not fit well. * * * This difficulty 
has, however, as we learn, been removed. A larger canula, specially constructed 
in this country, lias been substituted, and so the irritation, which was produced 
by the badly adapted canula, has disappeared." 

But the British Medical Journal Qxxed. On Feb. 25, the situation 
was very different. The favorable night of the 20th and 21st was 
followed by a day less favorable. During the afternoon coughing 
had been a very prominent symptom, as also during the following 
days and nights. In my opinion this was owing to the use of the 
insufflations of bismuth sub-nitrate, tannic acid and morphia. The 
expectoration was copious, brown in color, and at times showed 
more fresh blood than formerly. At a careful examination of the 
wound, Hovell asserted that the tracheal opening did not corres- 
pond to the middle line ; that for this reason the canula necessarily 
exercised pressure and caused irritation ; that the crooked incision 
was the cause of the continued disturbance, even though the Eng- 
lish canula was in use. At once, this assertion appeared in a num- 
ber of English and German newspapers. The most drastic report 
was given in The World : 

" The true cause of all the suffering was a bungling and badly performed trache- 
otomy. The operator lost his head and made a long incision in the throat in- 
stead of merely the short one which was necessary. He was too nervous, so that 
only after a great effort was he enabled to find the trachea, which he finally opened 
too much to the right side instead of in the centre. Small wonder that it re- 
quired so much trouble to find a suitable tube." 

Y.\en i\\e British Medical Journal fell in line regarding Hovell's 
vision of the lateral incision. In No. 1419 we find: 

" We repeat that the late unfavorable condition of the illustrious patient is 
owing almost entirely to the badly-fitting tracheal canula. The operator appears 
to have been, which under the circumstances was quite natural, a trifle nervous, 
and as the trachea had been opened somewhat toward the right side, the difficulty 
of finding a fitting canula presented itself. Sir Morell Mackenzie, assisted by 
Mark Hovell and the well-known Parisian dentist, Dr. Evans, spent the greater 
part of a day in the construction of a canula that should meet all the special re- 
quirements of the case. Since this has been worn the Crown Prince feels in 
every way improved. He sleeps, his cough is less marked, and the expectoration 
has lost its sanguinary character which caused such great alarm." 

But this favorable appearance of the expectoration did NOT ap- 
pear up to the day of death, as the reports of the case prove. 

On March 4, and April 16, Prof. Waldeyer verified the presence 
of blood, as also of necrosed fragments, in the material coughed up, 
which we examined daily. 

The night from February 22 to February 23 was a particularly bad 
one. The quantity of admixed blood was very great. It aroused a 



66 CASE OF EMPEROR FREDERICK III. 

suspicion in my mind of pulmonary hemorrhage, which might pos- 
sibly result from a softening secondary carcinomatous deposit in this 
organ. As during this night Dr. Schrader had sat up with the 
patient, Sir Morell had the temerity to insist that his clumsy hands 
had caused an injury while changing the inner canula. This episode 
also found its echo in The Sfajidard, as well as in other papers, where 
it was said : " Had Dr. Hovell been permitted to visit the patient for 
the purpose of adjusting the canula, not merely twice during the 
night, but been allowed to watch at the bedside of the Prince, we 
should have heard nothing of disturbed rest." In fact, Mackenzie 
demanded that the watch at the bedside should be left entirely to him 
and Hovell. Then the new canula would certainly give satisfaction. 
His wishes were complied with, but the expectoration became 
more copious and the quantity of blood more alarming. Mackenzie 
admitted this, and, on the occasion of the morning visit of the 24th, 
he apologized to Schrader, and said to me in the presence of the 
other colleagues that he felt convinced that his canula did not irri- 
tate less than mine. He desired, he said, to make some changes in 
it to better adapt it to existing circumstances ; until then I might 
introduce my instrument. The condition of the illustrious patient 
underwent no change, although different powders were blown into 
the larynx either by way of the wound or through the opening in 
the upper portion of the canula. There were intervals of sleep, 
lasting an hour or so, and some days that were favorable, during 
which His Imperial Highness promenaded in the garden or sat on 
the balcony. His general condition was good and less disturbed by 
the higher temperature of the evening and by headache ; the appetite 
being also satisfactory. Now and again, he was annoyed in swallow- 
ing, by pain radiating toward the left temple and ear. The copious 
expectoration prompted me, although I could not support this by 
percussion and auscultation, to consider the possibility of a pulmo- 
nary affection. The sputa had at times the appearance of raspberry 
jelly, and the illustrious patient occasionally complained of sharp 
pains below the left clavicle and over the entire left thorax. As the 
presence of gangrenous processes had been established since January 
it was probable that since that time the morbid material had either 
flowed or been aspirated into the air-passages. The development of 
putrid bronchitis, as well as peri-bronchial foci, was to be expected 
daily. The breaking down of secondary cancerous deposits in the 
lungs seemed to me, however, to be more probable. I mentioned 
these fears to my colleagues at the consultation of the 24th, and 
pointed to the compresses, which were saturated with a brown and 
raspberry colored expectoration which had escaped through the 
canula during the previous night. If my suspicions of a pulmonary 



DR. BERGMANN'S REPORT. 67 

affection were well grounded, then a change for the worse must of 
necessity be feared, a fear which led me to express a wish that the aid 
of a clinician versed in internal diseases be secured. This led to the 
conclusion that the disease had commenced to be a general one, and 
that in conformity with my opinion to the effect that an ulcerative, 
destructive carcinomatous deposit existed in the lungs, the specialist 
for throat diseases was no longer in place, and that the case should 
now be entrusted to the physician for internal diseases. It was 
unanimously agreed by the physicians to suggest, in the highest circles, 
that Kussmaul be called, a suggestion which was at once approved. 
By direction of the same high authorities I immediately telegraphed 
to Strasburg. 

[Prof, von Bergmann's report is continued on pages 76-86.] 



CHAPTER VIII. 



REPORT OF PRIVY COUNCILLOR DR. KUSSMAUL. 



As commanded by Her Imperial Highness, the Crown Princess 
of Prussia and the German Empire, I started on Feb. 24 for San 
Remo, where I arrived on the evening of Feb. 25. I was there in- 
formed by Prof, von Bergmann that I had been summoned to make 
an examination of the chest of His Imperial Highness, the Crown 
Prince, to ascertain, if possible, the source of the red expectoration 
which had been flowing through the canula since the performance 
of tracheotomy, and to determine whether it had its origin in the 
lungs. 

On Feb. 26, in the early morning, about 100 grammes of the 
sputa that had been brought up during the previous night were sent 
me for inspection. The sputa, in the main, looked red, raspberry 
colored, and appeared to be a uniform mixture of blood and mucus, 
only one specimen presenting a gray appearance and suggesting pus 
in a state of decomposition. This proved to be, under the micro- 
scope, pus pure and simple. The red mucus masses consisted, in 
the main, of blood corpuscles and pus corpuscles, with an admix- 
ture of small pigmented bodies, isolated and coalescent epithelium 
flattened, and also round, transparent cells, and in one prepa- 
ration there was a preponderance of so-called epithehal or cancroid 
pearls, some round in shape, others elongated. I counted more 
than a dozen of these in a very small microscopic specimen. 

I was informed by Dr. Bramann that these pearls had been found, 
with the exception of one day, for the last 12 days. This one ex- 
ception was a day when it became necessary to interrupt examina- 
tions. He showed me a number of prepared specimens, all of which 
contained more or less of these pearls. In addition he had two 
specimens which showed elastic fibres. These did not give the al- 
veolar distribution of the elastic fibres as found in abscesses of pul- 
monary cavities. In one of the preparations they appeared to be 
interwoven ; in the other, which contained them in larger number, 
they were disposed in bundle-shaped masses. 

At about nine o'clock I had the honor to be received by the 
Crown Princess and, shortly after, by His Imperial Highness. I 
had seen the Crown Prince at the five-hundreth yearly jubilee of the 
University of Heidelberg. Then in the full strength and vigor of 



DR. KUSSMAUrS REPORT. 69 

health, he now appeared emaciated and of bad color, only the ex- 
pression of the face retained the old, winning, friendly look un- 
changed. It may be that the cause of the rather poor appearance 
of the Crown Prince could be explained by a troublesome and re- 
laxed condition of the bowels, which had existed during the last few 
days, and disturbed his rest at night, and that during this time he 
had eaten no solid food, and was also harassed by a recurrent cough, 
febrile disturbance being also present in a shght degree. 

The former tendency of His Imperial Highness had been rather 
in the direction of constipation, and the diarrhoea, which was not 
very marked, was owing, as Dr. Schrader assured me, to some porter 
which had been taken. I now proceeded to examine the chest, 
previously feeling the pulse and examining the neck. The pulse, 
but for a slight acceleration, presented no feature worthy of note. 
About the neck, especiaUy near the larynx, I could feel no large 
swelling. To the left, close to the larynx, I thought I discovered a 
small, deep, slightly swoUen lymphatic gland. The site of the in- 
cision at the trachea had healed kindly; the mucous membrane at 
the posterior wall, as far as I could see, looked very slightly injected 
and was not ulcerated. 

The respiratory movements of the thorax were regular and even, 
in fact, such as are found in normal lungs. Percussion everywhere 
gave normal sounds. During auscultation I heard on both sides, 
deep down to the boundaries of the lungs, loud and clear vesicular 
respiration ; only at the back and high up, and then only during 
deep respiration, did I find slight bronchial breathing. I could not 
find rales anywhere ; only posteriorly, high up to the left side, I 
sometimes heard slight crepitation during inspiration. Respirations, 
during the last few days, had been from 20 to 23^, 

Dr. Mackenzie did not attend this examination. He had ex- 
pressed the wish that I examine only the chest, and that permission 
should not be given me to examine the larynx. I sought him and 
obtained his permission to make a laryngoscopic examination in his 
presence. This was done at 3 o'clock in the afternoon. I could 
only see that the epiglottis was not thickened ; behind it I discovered, 
in the region of the arytenoid cartilages, two flat, semi-circular 
swellings, which hid the interior of the larynx from view. 

On February 27, with Dr. Bramann, I made another examination 
of the sputa. During the night only very few red mucus sputa had 
been expect )rated, and no pus. Among the many specimens in 
which the epithelial pearls were looked for in vain, in only one was 
a large number found. On this day also the Crown Prince gra- 
ciously permitted an examination of his chest. As on the day pre- 
vious, I found everything in good order, and only once did I hear 



70 CASE OF EMPEROR FREDERICK III. 

on the right side, posteriorly and low down between the shoulder 
blade and spine, a slight, sonorous rale. 

Based on the result of these examinations, I arrived at the con- 
clusion that the red expectoration did not have its origin either in 
the lungs or bronchi. My reasons were as follow : 

1. With the exception of occasional crepitation and isolated 
sonorous rales, examination of the chest revealed nothing abnormal. 
These symptoms would have no weight ; surprise would rather be 
excited that sounds of this nature were not heard in greater number 
and more frequently in a patient on whom tracheotomy had been 
performed. They can, without doubt, be attributed to the presence 
of mucus which had flowed from the upper air-passages to the deeper 
pulmonary ones. 

2. The bloody mucus which for the last 14 days had been coughed 
up through the canula, contained, in two instances, elastic tissue and 
this could, with certainty, be attributed to an ulceration. Their 
whole disposition did not justify belief in their pulmonary origin. 

3. In addition, the mucus contained, in the 13 examinations 
during 14 days, specimens of epithelial pearls. As these had been 
found during some time past and had been detached in large quan- 
tities, I consider myself justified in the belief that the case was one 
in which an ulcerative process in newly-formed tissue was going on, 
in all hkelihood an epithelial tumor. 

4. A tumor of this kind could not have its seat in either the lungs 
or bronchi. There would be opposed to such an opinion, the elastic 
fibres found in the expectoration, as well as the absence of diagnostic 
physical syinptoms in the thoracic organs. A tumor of the lungs or 
bronchi undergoing ulceration, causing constant bloody expectora- 
tion mixed with elastic fibres and epithelial pearls, would, in one place 
or another in the chest, produce some symptoms of narrowing or ob- 
struction of the bronchi, contraction or possibly cavities. To say the 
least, one would expect to find a circumscribed modification of the 
respiratory sounds, rales, crepitation, or other symptoms. 

5. As Dr. Mackenzie, after a careful tracheoscopy, could discover 
no lesion of the trachea nor any ulceration or swelling that could 
stand in causative relation to the bloody expectoration, nothing re- 
mained for us but to look upon the seat of the production of the 
morbid material as being in the larynx, and owing to an ulceration 
of the epithelial growth which it contained. The mucus probably 
descended from the larynx along the tracheal wall, between it 
and the canula, and was then brought up through it during the 
paroxysms of coughing. 

I did not conceal from Dr. Mackenzie that I considered what I 
had found in the larynx to be a malignant epithelial growth. He did 



DR. KUSSMAUr S REPORT. 71 

not dispute the possibility of the correctness of my assertion, but 
did not confess to its absolute correctness. If my memory serves 
me, he intimated that the case might be one of epithelial neoplasm 
of a benign form, complicated with an ulceration of the mucous 
membrane of the larynx and perichondritis. I am not aware that 
such complications are ever present in benign epithelial growths. 
The entire progress of the case is not in favor of such an assumption. 

The above mentioned meetings between myself and Mac- 
kenzie had shown that he still persisted in his opinion regard- 
ing the non-cancerous nature of the new formation, but he had de- 
clared that if an authority like Virchow acknowledged that the speci- 
mens furnished by von Bergmann and Bramann demonstrated the 
reverse, he would declare himself as convinced, Virchow, at the 
time, was in Egypt, and could consequently not be reached. We 
were therefore compelled to propose another authority. At this 
time experiments had been made with canulge of various curves sur- 
rounded by a thin rubber covering, and this had led to a unanimity 
of opinion in the " canula question," in so far that Mackenzie ex- 
pressed himself as satisfied with the latest one that had been intro- 
duced. The wound surrounding the canula had long since healed 
and cicatrized. I could now consider my task, as far as the guidance 
of surgical after-treatment was concerned, as ended. I therefore 
made preparations to take the prepared specimens with me on my 
return to Berlin, and there to submit them to Prof. Waldeyer, who 
is a well-recognized authority on the history of the development of 
cancer. Mackenzie was in accord with this, and promised to abide 
by Waldeyer's decision. 

On the morning of Feb. 28, I was graciously dismissed by my 
most high masters, and was about commencing my journey home- 
ward, when a telegraphic command from His Majesty, the Emperor 
and King, kept me at San Remo. His Majesty desired that I should 
wait for the arrival of His Royal Highness, Prince WiUiam, who 
might be looked for on March 2, and endeavor to obtain a binding 
promise regarding the return of the illustrious patient to Berlin in the 
near future. To secure the fulfilment of this peremptory wish of His 
Majesty, I saw only one method, that was, to convince Mackenzie 
of the correctness of the diagnosis of cancer. I believed that he 
would then withdraw his opposition to the journey homeward, which 
would not be necessarily direct to Berlin, but first to Baden-Baden or 
Wiesbaden. I therefore secured the kind offices of the Imperial family 
physician. Dr. Leuthold, to bring Dr. Waldeyer to San Remo. Prof. 
Waldeyer arrived on the evening of March 3, and devoted the entire 
day to the most searching investigation, the result of which confirmed 
the conclusions we had arrived at after our microscopic examination. 



CHAPTER IX. 



REPORT OF PRIVY MEDICAL COUNCILLOR DR. WALDEYER. 



In conformity with the request of the physician of His Majesty, 
the Emperor and King, Dr. Leuthold, I proceeded to San Remo 
on March i, for the purpose of making an examination of the 
masses expectorated through the canula worn by his Imperial and 
Royal Highness, the Crown Prince of the German Empire and of 
Prussia, as well as the specimens from the same patient prepared by 
Privy Councillor Dr. von Bergmann and Dr. Bramann. On the 
morning of March 4, of this year, I received from the above-named 
attendant physicians of His Imperial and Royal Highness the fol- 
lowing : First, a number (perhaps a dozen) microscopic specimens 
preserved in glycerine ; secondly, a portion of the expectoration of 
the night from March 3 to 4. This was contained in a small glass 
capsule. Thirdly, on the morning of March 5, a small piece of 
gauze bandage containing the products removed from the canula a 
short time previously. Regarding number one, the above-named 
microscopic specimens looking to a coloration of the nuclei had 
been stained with Bismarck brown, which color proved to be well 
chosen. Their constitution, as far as could be detected under the 
microscope, was, in addition to masses of detritus, mainly pus cor- 
puscles, blood corpuscles and microbes: 

(a) Concentrically placed cells of the character of flattened 
epithelium, disposed in masses both round and oval ; 

(i^) Isolated large cells of the same character ; 

(c) In some of the preparations thin, partly dark and partly light 
fibres ; 

(d) Dark granular cells scattered here and there, so called granule- 
cells. 

The concentrically disposed bodies mentioned under a were either 
alone, or coalescent to the number of ten, imbedded in masses of 
detritus, pus-cells and blood corpuscles. The cells found at the 
periphery of these bodies were flattened, while in their centre a 
number of rounded and globe-shaped shining cells appeared. 
Frequently two or three of these bodies showed themselves, strung 



DR. WALDEYER' S REPORT. 73 

together like pearls and so disposed that they were connected to an 
elongated process, hookUke in form, by an accumulation of con- 
centrically-placed flat cells. Sometimes these processes were found to 
bifurcate. By slight pressure or by tearing apart, the constituents 
of the above-named round or elongated bodies could be easily iso- 
lated. It could then be seen that these bodies consisted, in the main, 
of large flat cells, with a clear boundary. Almost each cell contained 
a nucleus colored with Bismarck brown. Even in the unstained 
specimens could the nuclei be plainly descerned. The cells in their 
form_, size and refraction of light presented all the characteristics of 
pavement epithelium cells, such as found on the mucus surtaces 
covered therewith, among others, the true vocal bands of the larynx, 
and in those cancerous growths called " pavement epithelial cancer " 
or " cancroid." 

The number of pearls and processes found was remarkably large, 
being present in nearly all the specimens furnished by von Bergmann 
and Bramann, and also in those specially prepared by me. As 
already mentioned, they were disposed in masses ; and I counted m 
a number of specimens in one field of the microscope with a magni- 
fying power of 100 about 20 of these bodies. Also the isolated 
cells mentioned in b showed the same characteristics, and were with 
Uttle difficulty distinguished from the pus-cells. The fibres mentioned 
in c were, in part (this according to the statement of Dr. Bramann — 
as they were absent in those specimens freshly prepared by me), 
unaffected by the addition of acetic acid. This fact, as well as the 
strong refracting power of Hght, their partial curly and partial 
straight distribution, led them to be recognized as elastic fibres. 
With this position and general form, these fibres did not, in any 
instance, show a typical tendency to a regular recurrent form, that 
is, as if they had surrounded small, round spaces. 

Another portion of the fibres appeared wavy, was disposed in 
small bundles, was weaker regarding the refraction of light, and was 
probably composed of connective tissue fibres. The cells mentioned 
in c/, as well as the microbes and pus-cells, were present in nearly all 
expectorations from the air-passages, and presented no special diag- 
nostic characteristics. We must view, however, as an important 
fact the free presence of red blood corpuscles in all the specimens. 

The fresh matter of March 4 and 5 was tenacious, had a generally 
red coloring, with here and there grayish yellow spots. Denser 
masses were not visible to the naked eye, and were not discovered 
when the matters were examined in liquids, such as distilled water, 
diluted acetic acid, diluted solution of caustic potash, glycerine, 
etc., with one exception, which requires mention. The microscopic 
examination led to the same conclusions as contained in that sub- 



74 CASE OF EMPEROR FREDERICK III. 

mitted to me by Dr. von Bergmann and Dr. Bramann as the out- 
come of their investigations. I desire to emphasize that the numerous 
red blood corpuscles did not seem to have undergone any change, 
and appeared as if they had only just escaped froxn a vessel. Besides 
this, as already observed, fibres were absent. 

In the expectorated masses, which I found in the gauze bandage, I 
found a hard, uneven fragment, irregular in form and of about the 
size of a large lentil. The macroscopic as well as microscopic 
examination proved it to be "hyaline cartilage." 

Small sections of this fragment showed it to be covered with de- 
generative connective tissue and elastic fibres. On this surface the 
cartilage cells were flattened and disposed parallel with it. The 
other surfaces had a gnawed appearance, and were covered with 
little breaks and crevices similar to Howship's lacunae in bony tissue. 
In these crevices were contained masses of detritus and round cells, 
with which were mixed elements closely resembling epithelial cells. 
At one point, such epithelial cells in large masses were found. The 
above-named results, combined with the origin of the specimens, 
there being a canula in the trachea, lead to the following conclusions ; 

1. The concentric bodies which were found (pearls or processes) 
are' undoubtedly cancroid bodies, having their origin in a can- 
cerous new formation. 

As evidence of this we have first, their formation ; secondly, their 
size and shape ; thirdly, their great number ; fourthly, our inability 
in the case before us to attribute their production to any existing 
normal process, or to any other pathological one. 

2. The cancerous neoplasm (provided the air-passages do not 
communicate with a cancerous deposit existing elsewhere) must 
be situated in the air-passages. 

3. In all likehhood, it has its seat in the larynx above the canula. 
In support of this we have the fact that, first, the character of the 

pearls or flattened epithelial cells, bearing in mind that epithelial can- 
cer of the air-passages is generally covered with pavement epithelium 
and springs from the true vocal bands; secondly, the fact that in no 
instance did the discovered elastic fibres show an alveolar distribu- 
tion which would justify the assumption that possibly the new for- 
mation might be in the lungs ; thirdly, the fresh character of the 
blood cells present, this circumstance being of itself, however, of no 
special significance ; fourthly, the dimensions of the small piece of 
cartilage found in the expectorations of March 5. A piece of the 
same size coming from a bronchial or tracheal cartilage would not 
be easily found, as the fragment was the same in all its dimen- 
sions. 



DR. WALDEYER'S REPORT. 



75 



4. The cancerous formation must be undergoing an ulcerative and 
necrotic process of disintegration. This process has attacked 
the affected organ, the larynx. 

In support of this, first, the presence of numerous, isolated cancer 
cells, as well as detritus, pus and blood in the expectoration ; sec- 
ondly, the presence of elastic and connective tissue fibres (in Bra- 
mann's specimens) ; thirdly, the small piece of cartilage covered 
with crevices owing to absorption. 



CHAPTER X. 



PROF. VON BERGMANN'S REPORT. — (Continued.) 



I brought Mackenzie to Waldeyer, who explained to him, in the 
most exhaustive manner, what the microscope had revealed to him, 
and with the aid of specimens demonstrated to him clearly the pres- 
ence of cancer. Mackenzie then declared, as he also did on Nov. 9, 
that there was now no doubt in his mind regarding the correctness of 
the diagnosis of cancer. I now urged on him the advisability of 
having the patient journey homeward, and I was fortunate enough to 
secure from him the following written assurance : 

" I, the undersigned, hereby obHgate myself, immediately on the appearance of 
grave symptoms in the disease of His Imperial and Royal Highness, to insist on 
his immediate return to Germany, a measure which I would, at all events, sug- 
gest when the weather becomes warmer. 

" MoRELL Mackenzie." 

At the next medical consultation I mentioned the results of Wal- 
deyer's investigation and Mackenzie's recognition thereof. As the di- 
agnosis accepted by the physicians was an unanimous one, I sought 
to secure a unanimity of opinion in the matter of treatment also. 
Mackenzie had, a short time previously, received a new canula from 
England, constructed on the principle of the first one proposed by 
him, and introduced on the 20th. It differed, however, in that it was 
longer and broader, was not bent at right angles as were the former 
ones, but presented an obtuse angle, therefore approaching our canula 
in construction. I declared myself in accord with its use in the case, 
but begged that he would desist from frequent changing of the canula, 
as had been done lately, and that he would also refrain from the in- 
sufflation into the larynx of powder and caustic remedies, or at least 
to reduce their use to a minimum. As all these suggestions received 
unanimous approval, Mackenzie personally begging me to have Bra- 
mann remain after my departure to meet any possible surgical con- 
tingencies that might arise, I made my preparations to journey home- 
ward. 

The outcome of this, our last consultation, was the source of the 
bulletin of March 6, which was construed in so many ways : 

"The undersigned declare that, regarding the nature and judgment 
of the disease of His Imperial and Royal Highness, no difference of 



DR. BERGMANN'S REPORT. 77 

opinion exists among them ; and they also agree that there is no im- 
mediate danger of an unfavorable change in the disease. The sole 
responsibility is at present, as before the operation, vested in Sir 
Morell Mackenzie, whose name is subscribed with ours." 

It was my proposal, as our illustrious patient had been assured that 
the physicians who had expressed their opinion on Nov. 9 were in 
error and that we had to deal with only a laryngeal disease that could 
be cured by tracheotomy, to keep secret from him Waldeyer's opin- 
ion. For this Mackenzie thanked me. It is true that only lately the 
press learned the facts regarding Waldeyer's and our decided anatomi- 
cal diagnosis. The newspapers accepted the tenor of the bulletin 
as being an acknowledgment of the correctness of Mackenzie's 
views. 

The days following March 6 were fraught with most important and 
dire events. On the morning of March 10, the Emperor Frederick 
III. commenced his journey homeward, and arrived at the castle of 
Charlottenburg at 1 1 in the evening. 

Eight days after the return of the Kaiser, Dr. Wegner wrote me 
to take part in the examination and treatment of His Majesty. This 
was subsequent to an imperial decree, which gave the responsible 
management of the case entirely into the hands of Mackenzie. My 
first visits were on March iS and 25. I examined the larynx by strong 
sunlight. The epiglottis was still unaffected. Only the thickening in 
the region of the left ary-epiglottic fold was larger and showed a greater 
elevation, as also an ulceration toward the median line. A view into 
the deeper portions of the larynx was entirely impossible. Palpa- 
tion revealed an unmistakable enlargement of the larynx. In addi- 
tion to that, a hard infiltration had developed along the trachea from 
the cricoid cartilage to the upper boundary of the incision in which 
the canula was situated, and extending to both sides of it. Only the 
lower portion, between the canula and the sternum, seemed unim- 
paired. The expectoration and attacks of coughing remained the 
same as at San Remo. Especially on March 25 there were found 
many soft, dark, blood coagulse in the dressings. 

On the 29th, a large piece of cartilage was expectorated ; and a 
few days latter a number of pieces of necrosed tissue. This gave the 
reporters, who received their news directly from the castle of Char- 
lottenburg, an opportunity to report a favorable crisis in the course 
of the disease. The fragment of necrosed cartilage was accepted as 
corroborative evidence of the existence of perichondritis, and an 
attempt was made to again prove the correctness of this diagnosis. 
The reports of Wegner at this time, as also during the following 
weeks, mentioned headache, to allay which, as in San Remo, croton 
chloral and morphine were employed. Eight days latter, on Easter 



78 CASE OF EMPEROR FREDERICK III. 

Sunday, I plainly felt a hardening under the canula, and an increase 
of the lateral hardening which had previously existed. On the left 
side, this process extended to the upper portion of the clavicle, and 
the presence of enlarged lymphatic glands was easily established. 
Owing to this, the whole region presented a prominence, at the apex 
of which the shield of the canula was situated. The granulations, 
which formed the boundary of the opening, when the canula was 
removed, presented, especially at its upper portion, a dirty gray, 
irregular appearance, interrupted by depressions containing coagulse 
of the seize of a liemp-seed, and larger. Yellow points appeared 
everywhere, as also fragments of tissue, one of which I removed 
with the dressing-forceps. An attack of coughing which I witnessed 
was the same in character as in San Remo, and at the end, about 5 
cubic centimetres of brown ichorous matter were suddenly ejected. 
I took this specimen with me and examined it in company with Prof. 
Waldeyer. We found the same state of affairs as in San Remo, each 
microscopic specimen showing a number of cancroid pearls. The 
process of destruction was evidently on the increase. 

On April 8, I found the skin above and at the side of the canula 
replaced by a yellowish-red wartlike formation, of about the height 
of 5 millimetres. A portion of this was dark-brown in color, evi- 
dently gangrenous, another portion infiltrated with blood. Its hard- 
ness and deep furrows characterized it as a proliferating cancerous 
mass, an assumption which Mackenzie, however, rejected with the 
words : " This is certainly no cancer; this is only granulation tissue." 
I declared my firm belief in my view, especially as the hard infiltra- 
tion had spread to the deeper portions, and the canula had been 
forced partly out by the encroachment on its former seat of the now 
brown colored and deeply affected skin, and the underlying tumefied 
masses. The canula of which Mackenzie made use at the time con- 
sisted of a straight silver tube of about the length of 4 centimetres, 
into which, by means of a stout mandril, the inner tube was intro- 
duced, this being considerably, say about 6 centimetres, longer than 
the outer one. The projecting portion of this tube was flexible and 
articulated on the well-known principle of the lobster's tail. The 
outer short and straight canula was designed to project to the inner 
portion of the larynx, and from this the movable portion of the inner 
tube was to hang freely downward. Evidently, all this was designed 
to prevent contact with the walls of the trachea. I took the liberty 
of calling Mackenzie's attention to the fact that, owing to the short- 
ness and straight direction of the outer tube, this mighty as the result 
of the rapid growth of the tumor, be forced out of the opening. 
The only safety would lie in the use of a curved double canula,. 
which would enter deeply into the lumen of the trachea. My advice 



DR. BERGMANN'S REPORT. 79 

received no consideration at the hands of the managing physician, 
who assumed all responsibility in the case. 

On the morning of April 12, the nurse, whom I had installed to 
wait upon the patient at San Remo, sought me and announced that 
the preceding night had been a very bad one. The introduction of 
the inner canula could not be successfully accomplished, and the res- 
piration of the Emperor was attended with difficulty. I mentioned 
this to my assistant Dr. Bramann, and requested him to hold himself 
in readiness for the contingency which I had predicted on Sunday, 
that is, greater difficulty in the introduction of the canula. Sure 
enough, at about three o'clock in the afternoon I received from a 
royal messenger, who had not found me at home but at a consultation 
in a hotel in the city, the following letter from Mackenzie : 

" Dear Prof, von Bergmann : We have difficulty with the canula, and I would 
be glad to have you see the Emperor with me as soon as possible. 

"Yours truly, 

" MoRELL Mackenzie." 

The last four words were underscored. I departed with Dr. Bra- 
mann at once, stopping at my residence only long enough to take a 
few instruments with me. Here my servant had been asked through 
the telephone if the royal messenger had found me, and that I was to 
make haste. I had just left, when another question came through 
the telephone if I was on the way. I was received by Dr. Wegner, 
and learned from him what he had written in his journal: " The night 
was an uneasy one ; in the morning, a feeling of pressure about the 
chest. After removal of the canula breathing easier, as also when 
another shorter canula was introduced. From one o'clock in the 
morning and in the course of the day decided difficulty in breathing. 
The canula projected in part, a circumstance that had been dis- 
covered during the night by Beerbaum, the nurse. Breathing was 
very much impeded." 

There are many who have not yet forgotten that Mackenzie, in re- 
sponse to the article of the Kolnische Zeihmg, regarding its report of 
the events of April 12, insisted that the German physicians who were 
present in consultation on the morning of that day had, no more than 
he, remarked any respiratory disturbance and were ready to bear 
witness to this fact. There is a written report, made one hour later, 
regarding this matter, but it does not seem to be worded in favor of 
Mackenzie. 

I was ushered into Mackenzie's presence, and found him in the 
ante-room of the Emperor with a workman from the instrument 
manufacturer, Windier, in the act of bending a lead tube in such a 
manner that it might be introduced deeply into the trachea. In this 
way it was his object to quickly secure a fitting canula. I showed 



8o CASE OF EMPEROR FREDERICK III. 

him I had one of Hahn's canulse, having exactly the curve which he 
approved, and gave it to him for inspection. Mackenzie expressed 
himself willing to have its introduction attempted. 

I was frightened to find the illustrious patient sitting on a chair suf- 
focating. The cheeks and lips were blue, there was inspiratory stridor 
which could be. heard in the adjoming room, inspiration was accom- 
plished with difficulty, bringing all the muscles into play, and as the 
coat was open visible retraction of the scrobiculus became apparent. It 
appeared to me that in a few minutes death by suffocation would take 
place. I thought that no time was to be lost, ordered one of the at- 
tendants, after I had obtained Mackenzie's permission to call my as- 
sistant Dr. Bramann, and immediately proceeded to examine the 
opening Surrounding the canula the enlargements had become 
much higher and broader, and had, in some parts, become gangren- 
ous, there being an extension of the hardness in the deeper portions, 
so that the region of the neck in which the canula lay projected like 
a short flattened comb. Only the outer canula was in place. 

In response to my question, how long since the articulated inner 
tube had been introduced, the attendant answered: "Since early 
this morning." Mackenzie added that a number of attempts had 
been made to introduce it, but in vain. While on the Sunday 
previous, that is, only four days before, I had been able to look 
deeper into the wound and to see the posterior wall of the trachea, 
on this occasion it was not discernible. Large, round red ex- 
crescences projected from the deeper portions and from the sides 
into the lumen of the opening, entirely obstructing the passage to the 
trachea. The outer tube reached only to, and not into the trachea. 

I explained to Mackenzie that prompt action was necessary. If 
we did not succeed in introducing the canula, then we should be forced 
to use large retractors to pull the edges apart and expose the tracheal 
opening ; and if this did not succeed, we should have to perform an 
operation attended by loss of blood ; that is, dilate downward with a 
probe-pointed knife. Mackenzie expressed himself as in accord with 
everything, and praised the long, blunt retractors which I had brought 
with me. He posted himself behind the illustrious patient, supporting 
the head of His Majesty, a position which did not suggest to me his 
intention to introduce the canula in person. I endeavored to intro- 
duce the canula but did not succeed. I was prevented from accom- 
plishing this by the encroachment on the entire canal of the projecting, 
exuberant granulations. I then placed the canula to one side and 
grasped the retractors. In the meanwhile, Bramann had entered and 
taken charge of the retractors. Even now I made no progress with 
the canula, while the difficulty in breathing of the illustrious patient 
became more and more marked and alarming. I therefore attempted 



DR. BERGMANN'S REPORT. 8i 

to remove the fungus masses from the opening of the trachea with 
my finger, having previously, as may be well understood, thoroughly 
disinfected my hands in a basin containing a solution of carbolic acid, 
and then placed the retractors in position. After I had accomplished 
this, holding them in my hand, Bramann introduced a canula of less 
marked curve, the identical one which he had employed at his 
operation on Feb. 9. 

The respiration of the Emperor became at once easy and free, 
which he denoted by a joyous movement and a grateful pressure of the 
hand. It is true that during my manipulation blood was lost, but 
only in small quantities. It is certain that some of this blood and 
broken down tissue, as was also the case with the ichorous masses 
from the larynx, had flowed into the trachea, but this was coughed 
up at once. With the introduction of the canula the oozing of blood 
stopped, and when, after a half hour, I left the sick room with Weg- 
ner and Bramann, the sputa again showed their former brownish-red 
coloration. The entire procedure of dilatation and introduction of 
the curved canula had occupied only a few minutes, 

Mackenzie and Hovell give the above an entirely different inter- 
pretation. Mackenzie claims that I was called merely as a matter of 
courtesy ; that I persisted in my desire to introduce the canula, but 
that my efforts were not attended with success, my assistant finally ac- 
complishing it, etc. A number of English newspapers, and, follow- 
ing them, the Berlin newspapers, heaped a mass of slander on me, 
all of this in face of the fact that the Emperor before my arrival was 
suffocating, and a few minutes thereafter was breathing freely. 

I and my assistant were not the only ones who found the Emperor 
in a suffocating condition. On the same day His Majesty made the 
impression on the minister of war, Gen. Bronsart von Schellendorff, 
who saw him between 12 and i o'clock, as one who was struggHng 
for air and breathing with difiiculty. Two hours later. Gen. von 
Albedyll, who had been summoned to attend on His Majesty, hastily 
called medical aid during. an attack of coughing, as he feared suffo- 
cation. The same fears regarding death by suffocation were expressed 
by Adj. -Gen. von Winterfeldt who, at three o'clock, urged Dr. 
Wegner to hasten my attendance. All the attendants of the Emperor 
declared that since morning they had marked with alarm the hourly 
increase in the difficult breathing of their illustrious master. When 
the Emperor learned that I had been summoned, he sent to the 
entrance of the castle to ascertain if I had not yet made my 
appearance. 

I believe that even those parties who saw in me the ill-bred man 
who, against the will of the managing physician, pushed himself for- 
ward to do a certain thing which was then done in as clumsy and 



82 CASE OF EMPEROR FREDERICK III. 

rough a manner as possible, will not deny the evidence regarding the 
danger of suffocation, and recognize that this was favorably modified 
by me after it had, according to the Archives of the Royal House- 
hold, existed unchanged for 15 hours. I submit it to the judgment 
of my colleagues to determine whether the mechanical removal of 
projecting cancerous masses can be invested with that importance 
attributed to it by Mackenzie in his communications to the Holldnd- 
ische Dagblatt and the Seccolo ; that is, a shortening of life of about 
six months. Modern surgery teaches quite the reverse regarding 
much more extensive mterference with cancerous growths in canal- 
shaped organs. It is looked upon as beneficial and tending to 
prolong hfe. 

Evidently, the breaking down of the carcinomatous deposits in the 
larynx had, during the last few days, made more rapid progress, and 
had, in addition, extended to that portion which had encroached on 
and grown out of the tissues surrounding the canula, for, on the 
evening of April 12, as well as on the following night, during which 
I remained in Charlottenburg, I learned that the Emperor had suf- 
fered from fever for the last six days. It was only on Friday, April 
6, after the illustrious patient had complained of more than ordinary 
lassitude and weakness, that a temperature of 38,4 Cent, was noted 
in Wegner's journal. These elevations of temperature, accompanied 
by slight chills, were noted every evening during the succeeding days, 
and were, according to Wegner's notes, " Saturday, April 7, 38,2 Cent." 
The boundary of the opening in the trachea showed more marked 
swelling, and was reddened and sensitive. While out driving in the 
afternoon at 5 degrees Reaumur, chilly sensations were complained 
of. Monday, April 9, temperature, 38,4 Cent.; Tuesday, the loth, 
in the morning, 38,2 Cent,, in the evening 38,6 Cent., etc. In 
spite of the fact that on the morning of the 13th, although the pre- 
ceding night had been a good one (the Emperor wrote that this night 
had been the best of any during the past week), an elevation of tem- 
perature 38,2 Cent, was noted. On this day, when I had left the 
castle at about 10 in the morning, the illustrious patient traveled to 
Berlin, accompanied by Mackenzie. I had urgently advised a post- 
ponement of the journey, and proposed, by a bulletin, to make 
known the successful change of the canula. But Mackenzie did not 
desire a bulletin. He thought it would be better to quiet the public 
by the Emperor's presence in Berlin. The journey did not agree 
with the illustrious patient. In the evening, he again complained of 
chills, as likewise on Saturday, the 14th. On Sunday, the 15th, the 
temperature in the morning had risen to 39,4. A bulletin issued at 
Charlottenburg before my arrival connected the fever with an inter- 
current bronchitis. As the fever, frequent respirations and general 



DR. BERGMANN'S REPORT. 83 

lassitude of the illustrious patient continued, Privy Medical Councillor 
Prof. Senator was called in consultation. He ordered antipyrin, which 
reduced the temperature on the morning of the 17th to 38,5. 
Coincident with this, expectoration had become more profuse. 
During attacks of coughing the patient would suddenly expel as much 
as a tablespoonful of a purulent, brownish fluid. I secured a portion 
of this on Monday to take with me. The pus presented no special 
characteristics, but in the brown fragments found in the dressing were 
manifest occasional cancroid pearls and connected layers of pavement 
epithelium. 

On the same day, that is, Monday, Privy Medical Councillor Prof. 
Leyden was asked to attend in consultation, and arrived at 10 
o'clock Tuesday morning. He, as well as Senator, could not dis- 
cover any disturbance in the lungs. We, therefore, in accordance 
with the expressed wish of Mackenzie, held a general consultation, 
looking to the discovery of the causes of the unfavorable progress 
of the patient. Mackenzie supposed that there was possibly out- 
side of the trachea, probably in the mediastinum, a cellulitis, owing 
to the forcible introduction of the canula on April 12, and that the 
fever was dependent on this inflammation. In opposition to this, 
I dwelt upon the difficulty of substantiating the presence of small 
deposits in the lungs. I insisted on the probabiUty of the existence 
of such deposits, as for some months there had been an ulcerative 
breaking down of the laryngeal cancer, and a flow of the products 
down into the bronchial tubes. The fetid odor of the breath, as 
well as the frequent respirations, 44 to the minute, and the hiccough, 
almost incessant since Saturday, led me to suspect putrid bronchitis. 
The increase in the expectorations was, in my estimation, owing to 
the progress and extension of the gangrenous breaking down of the 
tumor. Privy Councillor Prof. Senator gave a similar opinion. 

On Tuesday, April 17, fever had diminished, and, a short while 
after, pus was expectorated in large quantities. To this circumstance 
can be attributed Mackenzie's adherence to the belief that his 
diagnosis of a large abscess in the cellular tissue surrounding the 
trachea, and that it had broken through into the air-tract, was cor- 
rect. The British Medical Journal described this abscess, and left 
no doubt regarding its etiology. In No. 1426, on April 28, it wrote as 
follows : 

" From information from the most reliable source, it has become 
certain that at the introduction of the canula on April 12, a false 
passage was made. The hemorrhage at the time substantiates this. 
Positive proof can be adduced showing that the blame for this does 
not attach to the English physicians." 



84 CASE OF EMPEROU FREDERICK III. 

In the meanwhile, in the Kobiische, the National, and the Neue 
Preussische Zeitung, an expose of the events of April 12 appeared, 
and I was given a certain amount of credit for relieving the Emperor 
of his difficulty in breathing, regarding which any number of rumors 
had become current in the capital. As a result of this, there 
appeared the declarations which Mackenzie and Hovell had printed 
in the above papers, and which were not only couched in insulting 
terms regarding me, but spoke in the most hateful manner of my 
part of the treatment in the case of the Emperor. In the same 
aggressive way, a number of EngUsh journals discussed the events of 
April 12, simply declaring that they had gained their information 
from the two English physicians of the Emperor (see the Sunday 
Times of April 29, this year). As I saw in these attacks of Mac- 
kenzie an unjust attitude toward me, I, on the morning of April 25, 
after the Emperor's high temperature had subsided and his general 
condition had improved, and I had received another invitation to be 
present at the consultation, gave Mackenzie a letter, which he sub- 
sequently published. In this letter I wrote him that his explanations 
in the above-named papers compelled me to request him to hold no 
further speech or communication with me other than that demanded 
by professional consultations. A fact, until now unknown in the annals 
of medical consultations, that of two physicians called to a bedside, 
one openly insulting the other in political newspapers, impelled me 
to take a further step in the matter, because these attacks on a col- 
league had emanated from the castle of Charlottenburg ; that is, the 
ante-room of the Emperor. I begged Her Majesty, the Empress, 
to insist no longer on my acting as consultant rt^ith Sir Morell Mac- 
kenzie, and asked her to relieve me of this duty. My place was taken, 
on April 30, by the Chief Privy Medical Councillor Dr. Bardeleben. 

My retirement from treatment of the Emperor was placed in the 
worst possible light by Mackenzie in his well-known interview with a 
correspondent of the /fe// yl/d;// 6^as^//<?, on May 15, 1888. I need 
say nothing in refutation of Mackenzie's statement regarding the 
slight respect with which I was regarded at court. I simply desire to 
substantiate that this last attempt to heap reproach upon his German 
colleagues, who had originally called him to Germany and who were 
now pushed to one side by him, had been preceded by a hne of 
similar conduct. Running through the entire record of the deeply 
sad tale of suffering of our patient and much-tried Emperor Fred- 
erick, we find the efforts of Sir Morell Mackenzie to attribute every 
change for the worse in the condition of the illustrious patient not to 
the disease and its natural and necessary consequences, its progressive 
nature, etc., but to some action of his colleagues. 

Gerhardt was accused of transforming a benign growth to a ma- 



\ 



DR. BERGMANN'S REPORT. 85 

lignant one by his cauterizations. When, in November and in Febru- 
ary, in addition to Schrotter and instead of Kussmaul, I had suggested 
Gerhardt as consultant, I was answered that such a proposal would not 
be entertained, as he was responsible for the entire unfavorable course 
which the disease had taken. Further, Bramann by means of an in- 
correct incision, Schrader through a clumsy change of the canula, and 
I through the selection of an unsuitable one, had caused the bloody 
expectoration and injury to the trachea. Finally, my forcible intro- 
duction of the canula on April 1 2 was the cause of the unfavorable 
symptoms and change in the disease which had commenced on April 
6, as it had caused the formation of a large, flask-shaped abscess of" 
the mediastinum. But the autopsy showed the mucous membrane 
of the trachea, at the point where the lower boundary of our canula 
had rested, smooth, with no trace of a scar or any previous irritation, 
and the cellular tissue surrounding the incision in the trachea, showed, 
as the pathologist at the autopsy stated, " normal conditions." Com- 
parison with the lines in question will establish the correctness of this 
quotation by the minutes of the autopsy. Aside from the elongation 
caused by the stretching of the walls of the large cavity, into which 
the larynx and the trachea had been transformed, as reported by Bar- 
deleben, the gangrenous destruction of the carcinomatous infiltration 
extended into the trachea to the extent of two and a quarter centi- 
metres. Each of our canulse however, even the shortest, extended into 
the trachea from 4 to 5 centimetres. They were, therefore, without 
exception, in contact with healthy tissue. But from the time that I 
established the extension of a cancerous tumor to the canula, on 
March 25, it (the canula) was introduced directly through the pro- 
liferating and decomposing cancerous growths. 

I, as well as my colleagues whose reports are here embodied, re- 
mained silent to all accusations that were hurled against us. Only 
when the British Medical Journal, in No. 1426, of April 28, asserted 
that my silence was an evidence of guilt, I declared in the pres- 
ence of those of my colleagues who had elected me as their presiding 
officer, before the members of the Berliner medizinische Gesellschaft, 
on May 2, 1888: 

" If the British Medical Journal were not a sheet whose scientific 
value I esteem highly, I should still observe silence on this subject. 
But I must defend myself against it, not because I am in error, but 
because I, as well as every honorable British and German physician, 
must decline to discuss openly the events at the bedside of a patient." 

I have no reason to retract anything regarding this explanation, 
although it raised a perfect storm of indignation against me. Mac- 
kenzie, in particular, endeavored to utilize it to my injury in No. 1428 
of the B7-itish Medical Journal, and other publications, insisting 



86 CASE OF EMPEROR FREDERICK III. 

that I had made an anonymous attack on him, as I stood on terms of 
intimacy with the correspondents of both the great German and 
English papers, the Kohiische Zeihmg and The Times, represented 
respectively by Mr. Fischer and Mr, Lowe. I have not, up to date, 
the honor of an intimate acquaintance with these gentleman. I had 
met Mr. Fischer only once at a dinner in the house of one of my 
colleagues, in November, 1887, where he, as well as many others, 
had been introduced to me by my charming host. Mr. Lowe visited 
me at the time of his newspaper war with Mackenzie, eight days 
subsequent to Mackenzie's explanation in the German newspapers, 
therefore after my retirement as consultant to His Majesty. He 
asked permission to see the letter which Mackenzie had written me 
on the 12th. I did not hesitate to show him this, as I had already 
shown it to a number of friendly colleagues and to those of my 
superiors who had asked to see it. At the same time, however, I 
begged Mr. Lowe not to press me further. I did not care to give 
any information regarding it to the press. Mr. Fischer and Mr. 
Lowe are quite ready to substantiate the truth of this assertion. The 
Kolnische Zeittnig, the Neue Preussiche Zeihmg and the Natmial 
zeitimg\\dcvQ already made known through their columns that I never, 
either directly or indirectly, had any relations with them. We must 
assume that the editors of these papers purposely tell an untruth, and 
that the statements of Mr. Fischer and Mr. Lowe are also incorrect, 
or come to the conclusion that the story of the " anonymous attack," 
which Mackenzie and the press controlled by him conjured up, must 
be relegated to where it belongs — to the domain of the fable, a 
fable conceived and designed to excuse Sir Morell's attacks on me, 
and the publicity which he had given to facts connected with the case. 
Not a single reporter can say that while Gerhardt, Bramann and 
I were at the bedside for treatment and consultation, one word 
regarding the case was uttered by us. Not a single interviewer 
ever liad occasion to report any conversation with us, while the 
official reports have verified the correctness of the list of 14 corres- 
pondents who were supplied with cards of admission and were re- 
ceived daily by Mackenzie in the castle of Charlottenburg ; and 
English, as well as German and American newspapers, contained 
long columns almost weekly of- reports of the conversations which 
he held with the reporters. 

The disease of His Majesty was arrested in its progress only a 
short time. The exacerbations of fever during the evening did not 
stop. In the first place, it was a slow, hectic sinking, and later, when 
pneumonia made its appearance, the end came quickly. The follow- 
ing report of Privy Medical Councillor Dr. Bardeleben records the 
final events. 



CHAPTER XI. 



REPORT OF CHIEF PRIVY MEDICAL COUNCILLOR PROFESSOR 
DR. BARDELEBEN. 



Monaay, April 2,0, 1888. — I saw His Majesty, Emperor Frederick 
(in response to the command which had reached me on the previous 
evening), for the first time, in the castle of Charlottenburg The 
shield of the double canula in the larynx was half surrounded by red, 
spongy growths, which impressed me as cancerous formations. The 
lower margin of the shield sank into these growths. When I called 
the attention of Sir Morell to the circumstance, he promised me that 
on the next day he would see to it that a canula in conformity with 
my wishes should be used. At the consultation with the attending 
physicians which followed, I asked the question if there was one 
among them who did not look upon the disease of His Majesty as 
cancer, and asked that those that dissented should give voice to 
their opinion. There was no response from any of the gentlemen 
present. I therefore specially emphasized in my report that we were 
of one opinion in our diagnosis. 

Tuesday, May i, 9 ^. M. — Sir Morell removed the old double 
canula, following which fetid masses of tissue and about 50 grammes 
of malodorous pus were expelled, v>^ith a cough, through the opening 
in the trachea. Adherent to the canula removed was found a piece of 
cartilage of about i centimetre in length and a trifle over i millimetre 
in width and thickness. The new canula, which had a shield of the 
shape suggested by me the day previous and the edge of which did 
not cut into the granulations, was introduced by Sir Morell without 
difficulty. The canal, as far as could be seen, was filled with 
smooth, red, proliferating tissue, which appeared to have a harder 
structure than that surrounding the external opening. The source 
of the pus could not be determined. At all events, the opening in 
which the canula was situated was, in itself, of insufficient extent to 
produce and hold such a mass of pug. On palpation I found the 
neck in the region of the larynx less resistant than in a healthy state, 
and not swollen. On the other hand, the tissue surrounding the 
opening felt hard to the touch. I discovered no enlarged glands in the 



88 CASE OF EMPEROR FREDERICK III. 

neck, only on the left side and in the region of the clavicle I found 
a hard, not clearly circumscribed space of about the size of a filbert, 
which, however, did not project. I was compelled to make my 
examination a very hurried one, as the physicians assured me that it 
was disagreeable to His Majesty. 

Wednesday, May 2. — I found the canula in good position, the 
granulations not pressed upon by the shield. Much pus had been 
again coughed up through the canula. Swallowing was said to have 
given some pain. Temperature, which was taken under the tongue, 
and the pulse, do not seem to accord well ; the first is said to be 
normal, or nearly so, while the latter is constantly above 100, which 
in a man of the physique of His Majesty, especially while resting 
quietly, is in excess of normal. 

Friday, May 4, 9 A. M. — We were informed at the consultation 
that the previous night had been a good one. The improved 
appearance of His Majesty corroborated this. The purulent expec- 
toration was still copious. 

Sunday, May 6, 9 A. M. — I again discovered the presence of 
copious, purulent and bad-smelling expectoration. The decoction of 
condurango had not been attended with any appreciable success, and 
it was replaced by a decoction of calisaya. 

Monday, May 7. — The purulent discharges continue. 

Wednesday, May 9. — At the change of the canula, which was 
effected without any difficulty, it was noticed that the deposits 
surrounding the opening had entirely disappeared, and that the 
opening itself had now smooth, clearly-cut edges. The surrounding 
skin was not even reddened. 

Friday, May 11. — The purulent expectoration has diminished, 
but retains its bad odor. 

Monday, May 14. — The general condition has improved. The 
frequency of the pulse has diminished, but His Majesty has disagree- 
able sensations in the pharynx, and the uvula is swollen. I can 
discover no grounds on which to base Sir Morell's fears regarding a 
perforation of the oesophagus. There is nothing present that would 
suggest that the lower portion of the canula exercises any pressure 
on the posterior wall of the trachea. 

Wednesday, May 16. • — There is an improvement in the general 
condition. 

Friday, May 18. — No appreciable change. The malodorous ex- 
pectoration continues. 

Saturday, May 19. — Change of canula presented no diflficulties. 
The granulations on the neck are beginning to sprout and grow with 
renewed vigor. I suggested the use thereon of subnitrate of bismuth. 

Monday, May 21. — General condition less favorable. The granu- 



DR. BARDELEBEN'S REPORT. 89 

lations covered with bismuth are black, showing clearly that decom- 
posing liquids or gases have come in contact with it. 

Wednesday, May 23. — In the main, the same conditions. 

Friday, May 25. — -The granulations surrounding the opening, par- 
ticularly at its lower border, have become more marked, and surmount 
an easily recognized hard elevation. 

Saturday, May 26. — I was called to Charlottenburg on account of 
the necessity of changing the canula. This was accomplished with 
ease, but was accompanied by a very copious purulent expectoration 
of a putrid odor. 

Monday, May 28. — The exuberant granulations continue, but ap- 
pear to have a tendency, owing to the bismuth, to become detached 
on the surface. 

Wednesday, May 30. — -The environment of the opening presents 
the same features. Evidences of a perforation of the oesophagus are 
not present. The malodorous discharge is still very copious. Appe- 
tite continues poor. The evening temperature has, during the last 
few days, been about one degree above normal. 

Friday, J^ime \. — Last consultation at Charlottenburg. No appre- 
ciable change, the general condition certainly no worse. Granula- 
tions about the opening more exuberant. The opening itself seems 
to have grown in size. 

Sunday, ^ttne 3. — First consultation in the castle of Friedrichskron. 
The unfavorable sequelae which the change of residence had led us 
to fear did not occur, though the granulations at the opening have 
increased and grown, but, owing to the exhibition of bismuth, are less 
sensitive. Its continued local use is to be faithfully observed. 

Wednesday, J^une 6. — The copious expectoration with fetid odor, 
and the rise in the evening temperature, continue. 

Friday, yime 8. — It was reported that during the previous night, 
while drinking milk, some of it flowed from the tracheal opening. 
From this it was concluded that a perforation of the oesophagus had 
taken place. I called attention to it, that with a perforation of 
the oesophagus in all probability quantities of liquid would find 
their way into the air-passages, and that it was more probable, if a 
perforation did exist, that it would be found in the neighborhood of 
the larynx, or at the boundary between larynx and trachea. The 
canula was so situated that it would not exercise pressure on the pos- 
terior wall of the trachea. It was then generally conceded that the 
point of perforation, if it existed at all, must be located near the 
larynx ; but that the flow of milk through the tracheal opening might 
be owing to the entrance of milk into the glottis, which had been 
much modified in form through the morbid processes going on there. 
It was at once decided to introduce a Trendelenburg's tampon-canula. 



90 CASE OF EMPEROR FREDERICK III. 

Saturday, June 9. — In the evening I was called to Friedrichskron, 
where I introduced and inflated the tampon-canula without difficulty. 
The exuberant granulations surrounding the opening had changed to 
black, dry, fetid masses, and separated without hemorrhage. 

Sunday, June 10. — Swallowing is much impeded by the presence 
of the canula. The flow of milk, as also of the yolk of egg, through 
the opening not checked. This left no doubt that the perforation, if 
it existed at all, was above the canula. The strength of the patient 
rapidly failing, fever increasing. 

Monday, June 11. — Although liquid food is being taken in large 
quantities, and only a small portion lost through the tracheal opening, 
his powers are fast failing, the frequency of the pulse, and especially 
of respirations, increasing (44). 

Tuesday, June 12. — During the morning a large quantity of bad- 
smelling pus was discharged through the opening. As a large portion 
of the milk that had been taken escaped through the opening, it was 
resolved to nourish the patient through a flexible tube introduced in 
the oesophagus. I was commanded to carry this out, and for this 
purpose to return to Friedrichskron in the evening and remain there 
during the night. At noon, a half litre of milk was introduced, and 
in the evening one litre of milk with cream. Pulse in the evening 
116, temperature 39,5, respirations only 24. 

Wednesday^ June 13. — Early in the morning one litre of milk 
and cream was again introduced. The morning temperature was 38, 
respiration 24, but in the evening respirations rose to 60, pulse to 
130, and the skin appeared cyanotic. After the introduction of the 
milk in the evening the patient vomited. His strength was rapidly 
failing. I again spent the night at Friedrichskron. 

Thursday, Jtme 14. — The putrid odor of the masses discharged 
through the opening has become steadily greater. Failing strength 
is more marked, in spite of the frequent introduction of milk. In 
the morning pulse c\\o, respiration 48, at noon as high as 80; in the 
evening reaching 140. In the course of the forenoon, in response to 
the question of the minister of justice, when death might be ex- 
pected, I answered that the life of His Majesty would last only about 
24 hours longer. I gave the same information later to His Royal 
Highness, the Crown Prince, and to His Highness, Prince Bis- 
marck, in response to their inquiries. I also spent this night at 
Friedrichskron. 

Friday, June 15. — After a number of attacks of insensibility, 
and after a constant diminution of the powers of life and without 
any death struggle, death took place at 12 minutes after 11 o'clock. 
At half-past five o'clock in the afternoon, and assisted by Dr. Wegner 
and myself, the embalming of the remains was commenced by 



DR. BARDELEBEN'S REPORT. 91 

Medical Councillor Dr. Hartmann and the embalmer, Wickersheimer, 
with a Hquid that had been prepared by the latter, and after Dr. 
Wegner had established the most unmistakable proofs of death. 
The introduction of the necessary quantity of Wickersheimer's fluid 
through the large vessels of the neck was accomplished without diffi- 
culty. 

The gaping wound in the trachea, from which the canula had been 
removed, was covered at its margin with only a few hard elevations. 
The aforementioned masses had separated entirely. It was an easy 
matter to remove a large mass of fetid granulations from the greatly- 
dilated cavity of the larynx, the walls of which were non-resistant. 
This was accompHshed by introducing pledgets of cotton and then 
withdrawing them. The entire cavity was then filled with alternate 
layers of cotton and subnitrate of bismuth. 

At the close of this procedure, there was entire absence of the 
pre-existing and highly penetrating odor. The tracheal opening, as 
well as that which had been made to reach the carotid artery, was 
closed with sutures. 



By command of His Imperial and Royal Majesty, William II., 
Sir Morell Mackenzie and T. Mark Hovell were directed before the 
autopsy to declare what in their opinion had been the disease of the 
late Emperor. In response to this, they submitted the following 
report : 

"ScHLoss Friedrichskron, June 16, 1888. 
" It is my opinion that the disease from which the Emperor Friedrich III. died 
was cancer. The morbid process probably commenced in the deeper tissues, and 
the cartilaginous structure of the larynx became affected at a very early date. A 
small growth which was present when I first examined the late Emperor, was re- 
moved by me by several endolaryngeal operations, and though all the portions 
taken away were submitted to Prof. Virchow, he was unable to detect in them any 
evidence of the existence of cancer. Examinations of the sputa made at the be- 
ginning of March by Prof Waldeyer, however, led that pathologist to believe that 
cancer was then present. Whether the disease was originally cancerous or as- 
sumed a malignant character some months after its first appearance, it is impos- 
sible to state. The fact that perichondritis and caries of the cartilages played an 
active part in the development of the disease no doubt largely contributed to make 
it impossible to form a decided opinion as to its nature until quite recently. 

" Morell Mackenzie." 

"June 16, 1888. 
" In so far as my observations since last August permit me to form an opinion, I 
concur entirely with Sir Morell Mackenzie's views. 

"T. Mark Hovell." 



CHAPTER XII. 



MEDICAL MINUTES OF THE EXAMINATION OF THE REMAINS OF 
HIS MAJESTY, THE LATE EMPEROR AND KING FREDERICK III. 



ScHLOSS Friedrichskron, June i6, 1888. 

In the neck a straight wound of the length of 6^ centimetres 
closed with sutures and showing dry edges, to the right of which 
there is a flat, pale elevation of the height of 2 centimetres, width 
1,5, and thickness 0,5 centimetres. In the interior of the opening, a 
quantity of cotton and bismuth, after the removal of which an open- 
ing is revealed, having a depth of q centimetres, almost the same 
length, and gaping to the extent of 25^ centimetres after the removal 
of the sutures. The edges of the wound are rather hard, uneven and 
tense. An incision is made in the centre of the sternum, and extended 
sub-cutaneously upward and to the right at one side of the original 
tracheal opening, ending at the incision made in injecting the carotid. 
An incision through the elevation that has been mentioned, reveals 
slightly reddened tissue, whiter below, hard in consistency, and from 
which, when the surface is stroked, a whitish liquid exudes. This 
nodule is situated below the skin, partially imbedded in the sub- 
cutaneous tissue, and the underlying muscles are unaffected. A like 
incision is then made to the left. Here, too, the muscles at both sides 
appear normal, except above, where they appear very tense. Im- 
mediately in front of the larynx, a marked prominence on the left side 
becomes apparent, in the deeper portions of which a marrow-like in- 
filtration shows itself. 

With the opening of the thorax a well-marked ossification is seen 
on the first rib of the left side. In opening the chest the very 
pale, gray lungs become visible, nearly filling the pleural sacs, cover- 
ing the heart. On the left side, a number of small projections are 
seen, under which hardened spots can be felt, covered with relaxed 
layers of connective tissue ; only in one place, near the anterior margin, 
a rather clearly circumscribed, lobulated polygonal configuration, with 
dull, uneven surface is seen. The left lung, on being lifted out, 
appears externally and posteriorly, above and below, entirely free, 



MEDICAL MINUTES. 93 

contains air in its entirety even to the last portion of the lower lobe 
directly over the diaphragm. There is very little hyperstasis ; those 
portions at the base containing no air, show dilated bronchi, which 
are in part surrounded by hemorrhagic deposits. An incision reveals 
a large number of deposits in the inner portion of the lobe, the most 
of which present a strong, hemorrhagic, infiltrated boundary, showing 
a granular surface on incision, while in the centre there appear a large 
number of small, closely-grouped, yellowish-white nodules. In some 
places, deposits of the size of a pea show themselves, and are filled 
with purulent products. In other places, the mass is still firm. In 
the upper lobe are found a number of the same deposits, scattered, 
and containing a number of small, yellowish-white places. In the 
above-mentioned deposits at the anterior margin, in the interior of 
greatly dilated bronchi, are found thick, discolored plugs, while the 
surroundings show connective tissue induration. On dividing the 
bronchi in the lower lobe, they show general dilatation, thickened 
walls, the mucous membrane in folds corresponding to the long axis, 
and in these granular, discolored material. 

The state of affairs on the right side is very much the same. The 
apex is entirely free. In the posterior and lower portion, however, 
the same state of affairs, almost entire absence of air and the same 
small deposits and dilated bronchi. The pleural cavities contain 
nothing further. 

In removing the larynx the incision is made directly opposite the 
vertebrae and back, to the oesophagus. 

In the mediastinum anticum there is much adipose tissue, glands 
slightly reddened, otherwise no changes. Larynx and oesophagus 
are laid bare together, and ligatures applied. On the left side of 
the neck, in close proximity to the jugular vein, is found a lymphatic 
gland of about the size of a pigeon's egg, the interior of which has 
the appearance of marrow, with yellow spots here and there. In 
opening the oesophagus, and directly behind the cricoid cartilage, a 
deposit of brown and white membranes which, after being pushed 
aside, reveal not even a trace of perforation. Epiglottis large, 
smooth and margin normal. Ligamenta aryepiglottica, especially 
on the left side, somewhat swollen, oedematous, but not ulcerated. 
The posterior space between the arytenoid cartilages rather deep, but 
also not ulcerated. Finally, at the base of the epiglottis, to the 
left side, a soft nodule of the size of a cherry ; next to this a flat one, 
and further still a number of others smaller and of more recent 
formation. In addition, and connected with this, a large surface 
of the length of 9 centimetres, covered with decomposed fragments. 
The lower boundary of this is formed by the trachea. From there 
to the thyroid cartilage no cartilage is present, as also no other 



94 CASE OF EMPEROR FREDERICK III. 

tissue of the trachea. Of the thyroid cartilage, only the upper 
sections and the sides, with their cornua, remain. 

The distance of the lower end of the tracheal incision to the lower 
margin of the ulcer is 2j^ centimetres. This low margin has sharp 
edges, and extends through the mucous membrane at right angles, 
showing at its lower portion small gray granulations covering a 
surface of about half a centimetre. We then come to a normal 
mucous membrane covering the tracheal rings still intact. In the 
tissues surrounding the portion of the trachea still existing, no 
cicatrices and generally normal conditions. This ended the exami- 
nation of the remains, which were then again carefully closed. 

The macroscopic changes, which were noted by Waldeyer and 
Virchow, were then reported as follow : 

Cancerous destruction of the larynx, with secondary affection of 
one of the larger lymphatic glands of the neck on the left side, and 
below, and a cutaneous nodule on the right side near the wound, 
oesophagus intact. Gangrenous destruction of the upper portion of 
the trachea and its environment. Numerous dilated bronchi with 
putrid contents. In their neighborhood, broncho-pneumonic depos- 
its of a gangrenous nature. 

Count Stolberg-Wernigerode, Leuthold, 

MoRELL Mackenzie, von Bergmann, 

T. Mark Hovell, Virchow, 

VON Wegner, Waldeyer, 

Bardeleben, Bramann. 



CHAPTER XIII. 



REPORT OF PROFESSORS VIRCHOW AND WALDEYER REGARD- 
ING THE MICROSCOPIC EXAMINATION OF A NUMBER OF 
SPECIMENS TAKEN FROM THE REMAINS OF THE LATE 
EMPEROR FREDERICK III. 



1. The larger nodule at the insertion of the epiglottis shows ex- 
ternally unchanged mucous membrane with cylindrical epithelium ; 
in the deeper portions, however, alveolar changes with epidermal con- 
tents. The cells of the latter are large and well developed; concen- 
trically disposed masses of cells are not discovered. 

2. The nodule under the skin on the right side of the tracheal 
opening is covered with epidermis, thinner than usual, but in other 
respects unchanged, the cancerous process extending nearly to the 
surface. Its most marked development is in the deeper portions, 
where in places well marked nests of concentrically disposed cells are 
discovered. A number of normal elements, such as sweat glands, 
are found well preserved between the cancerous masses. 

3. The lymphatic gland at the left side of the neck has undergone 
marked changes. The normal structure has entirely disappeared and 
has been replaced by loose alveolar tissue, the spaces of which are 
closely filled with large, epidermal cells, many of which show fim- 
briated edges. 

4. The contents of the bronchi correspond to the description given 
by Virchow regarding the expectoration of May 19 in reference to the 
small masses found therein. In addition there are found, at numerous 
points, abundant collections of small, glistening, fat globules similar 
to milk globules. 

5. In the pulmonary deposits there are thick accumulations of pus 
corpuscles and cancer cells. The normal alveolar structure still plainly 
discernible. 

Rudolph Virchow, 

WiLHELM WaLDEYER, 

It is not considered necessary to pass judgment. (Einer Epikrise 
bedarf es nicht.) 



X^^I^T SEOOISTX). 



THE RKPORT OK 

SIR MORELL MACKENZIE. 



PREFACE. 



It has been a painful task to me to write the following pages, not 
because there is anything in the charges recently brought against 
me by some of my German colleagues, which I have the shghtest 
difficulty in meeting, but because I feel most keenly the unseem- 
liness of a controversy which must necessarily cause additional suf- 
fering to hearts which have already been tried beyond the common 
lot. Although the pamphlet issued from the Imperial Press at Ber- 
lin embodies accusations which amount to a charge of malpractice, 
I should have been content, so far as I am personally concerned, 
to leave my professional reputation to the judgment of impartial 
men. Under the special circumstances of the case, however, I feel 
it to be a duty which I owe to those exalted persons who honored 
me with their fullest confidence through thirteen months of terrible 
anxiety, to justify the trust which they placed in me. My position, 
as will easily be understood, was one of the greatest difficulty, owing 
not only to the overwhelming responsibility of the case itself, but to 
what I may call its external complications. I know of no instance 
in history in which a physician, who simply tried to do his duty to 
his patient to the best of his ability, has had to endure so much 
calumny and misrepresentation. I say nothing of the abuse and 
even threats which were liberally showered on me, for to these 
things I was utterly indifferent, and I can, therefore, claim no credit 
for despising them. But one must be more — or less — than man to 
bear deliberate and persistent distortion of his words and acts and 
motives with equanimity. It is true that the accusations were in many 
instances absurd, and even self-contradictory, but my assailants evi- 
dently acted on the cynical maxim attributed to Voltaire, " Throw 
mud enough and some of it is sure to stick ; " and from the nature 
of the case there were few, even among professional men, who 
could form a correct judgment on the facts as presented to them. 
Two things supported me in what would otherwise have been an 
intolerable position. First, my own consciousness of perfect integ- 
rity of purpose ; secondly, the absolute trust and delicate considera- 
tion with which from first to last I was trusted by my noble-hearted 
patient. No physician could wish for a patient more obedier^t to 



loo CASE OF EMPEROR FREDERICK III. 

his injunctions, more full of " sweet reasonableness, " than the ruler 
of the mighty empire of Germany. 

As there is a good deal of plain speaking in the following pages, 
and as the conduct of some of my German colleagues is discussed 
with a freedom which may seem unprofessional to those who have 
not read the attack which these gentlemen have made on me, I 
take this opportunity of saying that 1 have advanced nothing here 
with respect to my hostile colleagues which has not been publicly 
stated already, nor have I made any allegations except in self- 
defence in reply to charges against myself. I regret extremely that 
the controversy should have assumed such a tone, but I may remind 
my readers that I am in no way responsible for it. 

In conclusion I may be allowed to refer to some of the difficul- 
ties under which I have labored in drawing up this vindication of 
my professional character. I have been unable for obvious reasons 
to allude to several points, which, though not bearing on the purely 
medical aspect of the case, were yet most important factors in 
determining the course which was pursued. I think I have also some 
grounds of complaint against the Prussian government, which, 
whilst allowing my adversaries free access to the State Archives, 
refused me the same privilege. As I have shown in the body of 
this httle work (p. 246), these " official sources" are of a very mis- 
cellaneous character ; but among them there are important docu- 
ments relating to the case of the late Emperor which, in justice to 
me, should not have been kept from the public. Amongst others 
may be mentioned the protocols of Prof, von Schrotter, Dr. 
Krause, and myself, drawn up in November, 1887, and more espe- 
cially the written refusal of the Emperor (then Crown Prince) to 
submit to any other external operation than tracheotomy. The pro- 
tocols which it is proved that Profs. Gerhardt and von Bergmann 
sent in to the Haus-Ministerium would also furnish interesting 
reading, and would show what really were the views of these gen- 
tlemen before I was summoned to Berlin. The first report of 
Prof. Virchow would also be highly instructive. I can only 
hope that these documents and other matters bearing on this his- 
torical case will some day be made public. I at least have no 
reason to fear the full light of day. 

M. M. 

19 Harley street, W., 
October, 1888. 



SECTION I.-HISTORICAL. 



CHAPTER XIV. 



MY FIRST VISIT TO BERLIN AND POTSDAM. 



Reception by the Crown Prince. 

On the evening of Wednesday, May i8, 1887, as I was about to re- 
tire to rest after a day of hard professional work I received a message 
requesting me to proceed to Berlin to see His Imperial Highness, the 
Crown Prince of Germany. No hint was given as to the nature of 
the case, about which I had only heard vague rumors, to which I had 
paid no particular attention. There was no train that night, but I 
started the next morning, and reached the German capital on the 
afternoon of Friday, May 20, being met by Dr. Wegner, Physician- 
in-Ordinary to His Imperial Highness, and Deputy Medical Director- 
General in the German army. We drove at once to the Kronprhiz 
Palais, where I found rooms prepared for me. I had scarcely time 
to change my traveling clothes before the Hof-Marshal, Count 
Radolinski, came to conduct me to the Crown Prince. His Im- 
perial Highness received me most graciously, apologizing with the 
charming bonhomie which endeared him to all who knew him, for all 
the trouble which his throat was causing to other people, and in par- 
ticular for the long and fatiguing journey which it had entailed on me. 
He spoke in English with scarcely a trace of foreign accent, but his 
voice, though perfectly intelligible, was little better than a gruff 
whisper. His Imperial Highness offered to submit himself to ex- 
amination there and then, but on my venturing to suggest that it 
would be better that I should first confer with the doctors already in 
attendance, he at once acceded to my request. 

Introduction to my Colleagues. 
Thereupon I was taken to another room, where I found the fol- 
lowing physicians and surgeons assembled : Profs. Gerhardt, 



I02 CASE OF EMPEROR FREDERICK III. 

von Bergmann and Tobold, Dr. von Lauer, Physician-in- Ordinary 
to the aged Emperor, and Medical Director-General in the German 
army, Dr. Wegner, whom I have already mentioned, and Dr. 
Schrader, another military surgeon, who occasionally acted as Dr. 
Wegner's deputy in attending the Imperial family. With Prof. 
Gerhardt I was already personally acquainted, and he was known 
to me professionally as a physician who, in the midst of his labors 
in other departments of medical science, had found time to give 
some attention to diseases of the throat. Prof, von Bergmann I 
had heard of in connection with the Servian and Russo-Turkish 
wars, and I knew that he had been called from St. Petersburg 
to take the Chair of Surgery at Berlin after it had been de- 
lined by Prof. Billroth, of Vienna, and Prof. Volkmann, of Halle, 
to whom it had previously been offered. I had never, how- 
ever; seen him mentioned in laryngological literature, save as a 
somewhat unfortunate operator in a few cases of extirpation of the 
larynx. Prof. Tobold's name had at one time been familiar tome as 
that of one of the earliest throat-physicians in Germany ; but in the 
development of the speciality he had dropped almost entirely out 
of notice, and had grown to be little more than a noininis timbra 
to the present generation of practitioners, i confess that I felt 
some surprise that among those with whom I was invited to take 
counsel in a case of such importance there was not at least one of 
the leading German specialists in throat-diseases. Every laryn- 
gologist could, without any difficulty, name several men in Germany 
whose reputation is not confined to their own country; their absence 
here seemed to me so significant that I rather hastily concluded that 
the Crown Prince must be suffering from some obscure disease of 
which the laryngeal affection was only an accidental complication. 

The First Consultation. 

After I had been introduced to my colleagues, the consultation 
began. Dr. Wegner read a report of the case from the beginning 
up to the time that Prof. Gerhardt was called ih. It appeared that 
the Crown Prince had suffered from what was supposed to be 
catarrhal inflammation of the larynx, with great hoarseness, in the 
previous January, and that he had been treated with the ordinary 
remedies without result. I may here mention that, as I afterward 
learned, the Crown Prince himself always attributed the origin of 
his illness to a severe cold which he caught in the autumn of 1886. 
Whilst in the north of Italy, the Crown Princess and he had taken 
a drive one evening with the King and Queen of Italy. The 
coachman lost his way ; it became dark and chilly, and the Crown 



DR. MACKENZIE'S REPORT. 103 

Prince, who had no great-coat with him, felt as if he had taken 
cold. He told me that his throat had never been quite well since 
that evening. When Dr. Wegner had concluded his report, Prof. 
Gerhardt described the condition of the Prince's throat when he first 
saw it, and gave a general sketch of the treatment which he had 
adopted, without entering into details. I merely gathered that 
there was a small growth on the left vocal cord, which Dr. Gerhardt 
had tried to distroy with the galvano-cautery, and that the Crown 
Prince had then been sent to Ems, where he had spent some weeks 
without deriving any benefit. 

My First Examination. 

After hearing these statements, I proceeded to examine the case 
for myself. For this purpose we went into a darkened room, 
where I made a careful inspection of the Crown Prince's throat 
with the laryngoscopic mirror. I saw a growth about the size of a 
split pea at the posterior part of the left vocal cord; it was of a pale 
pink color, slightly rough on the surface, but not lobulated. The 
little tumor lay over iho. processics vocalis, but extended also a little 
way behind and below that point. In deep inspiration, the sharp 
receding angle formed by the junction of the membranous with the 
cartilaginous part of the cord was seen to be obliterated, its place 
being taken by a rounded prominence. On phonation a portion of 
the growth disappeared from view — a fact which showed that it was 
partly attached to the under surface as well as the side of the cord; 
in other words, the neoplasm was partly subglottic in situation. 
The mucous membrane covering the vocal cord was red in the 
neighborhood of the growth, but at the front part, for about one- 
fourth of its length, the cord was perfectly natural in appearance. 
There was no trace of ulceration on the growth, which, to the 
naked eye, bore the look of a simple wart or papilloma (as seen in 
Fig. i). The affected cord did not move with the same freedom as 
its fellow on the right side, the play of its fibres being hindered by the 
excrescence attached to it, which also prevented the two cords from 
coming together in the way required to produce clear vocal sound. 
The mucous membrane in other parts of the larynx was slightly 
congested and relaxed. Except for the loss of his voice, however, the 
throat gave His Imperial Highness no trouble ; there was no pain, no 
difficulty of breathing, no hindrance to swallowing. The Crown Prince 
was in every other respect a model of stalwart health, far stronger 
to all appearance than the average even of strong men. He came 
of a healthy stock, and had not impaired his fine constitution by 
excesses of any kind. He had, however, been subject to occasional 



I04 



CASE OF EMPEROR FREDERICK III. 



attacks of relaxed throat, and he had necessarily led a life of con- 
siderable exposure. He had had to use his voice a good deal both 




Fig- I- — Sketch of the growth as first seen. Of course the drawing does not show 
the lower, or rather under, part of the growth, which was the portion that was 
specially difficult to seize and take away. 

The following explanations may, perhaps, be useful to those unaccustomed to 
examine the larynx : 

In speaking of " right " and " left," it must not be forgotten that a laryngoscopic 
sketch represents the throat of a person placed opposite the observer. In the case 
of an ordinary familiar view, the relation of the two sides is at once apparent; 
besides which, certain features at once make it clear which side of the body is 
on view; but, in looking at a larnygoscopic picture, the two sides being actually 
identical, confusion arises. It should therefore be borne in mind that the right 
side of the larynx is opposite the left side of the observer, just as the right hand 
of a person would be opposite the left hand of a person standing in front of him, 
and the same remarks, of course, apply to the left side of the larynx. To get a 
proper idea of the laryngoscopic pictures in this book, it should be held in front 
of, and rather above, the reaaet, the upper part of the book being inclined for- 
ward at an angle of 45°. 

in the open air and indoors. This was the case as it presented itself 
to me. 

The Qiiestion of Diagnosis. 

When I had made my examination the other doctors and I with- 
drew^ in the ordinary way to discuss the matter. Profs. Gerhardt 
and Tobold gave a positive opinion that the disease was cancerous, 
and Prof, von Bergmann, though expressing himself more guardedly, 
substantially agreed with them,* All three were unanimous in 
thinking that a cutting operation from the outside would be neces- 
sary for the removal of the growth ; the precise nature of the surgical 
procedure that would be required was never, however, discussed in 
my presence. In fact, our consultations never reached the stage at 
which that question would have come up for consideration. When 
it came to my turn to speak, I said that " there was nothing character- 

* I was afterward informed by Dr Wegner that until I arrived Prof, von Bergmann had decl ned 
to take any responsibility with regard to the diagnosis. He had always said, " Gerhardt makes the 
diagnosis, I am only the operator." 



DR. MACKENZIE'S REPORT. 105 

istic in the appearance of the growth ; and that it was quite impossi- 
ble to give a definite opinion as to its nature, without a more search- 
ing examination." I pointed out that the opinion expressed by my 
colleagues had been come to on what seemed to me to be insuffi- 
cient grounds, and that they had omitted the most essential, and at 
the same time, the most obvious, means of arriving at a correct diag- 
nosis The first thing to be done was to pick off a piece of the 
growth through the natural passage and have it examined micro- 
scopically by an expert. Prof. Gerhardt said it would be difficult, 
if not impossible to do this on account of the awkward situation of 
the growth; and Prof. Tobold expressed a similar opinion. Whilst 
freely admitting that the operation in this case presented exceptional 
difficulties, I said that I thought it could be done, and that at any 
rate it should be attempted. I then turned to Prof. Gerhardt and 
said to him, "Will you try?" He replied, "I cannot operate 
with forceps." I next asked Prof, Tobold if he would make the 
attempt, but he also declined, saying, *' I no longer operate." These 
replies increased the surprise which I already felt at a case of such a 
nature having been entrusted to the hands of these gentlemen, for a 
throat-specialist who cannot use the forceps is like a physician who 
cannot use the stethoscope, or a carpenter who cannot handle a saw. 
I then expressed my readiness to attempt the operation, and it was 
unanimously agreed that, if I succeeded, the fragment removed 
should be sent to Prof. Virchow, who is universally admitted to be 
the greatest living authority on all matters pertaining to morbid 
anatomy. Although anxious to keep clear of controversial topics in 
this place, I must here interrupt my narrative for a moment to call 
attention to the eminently disingenuous manner in which this subject 
is dealt with by Prof. Gerhardt. He makes no allusion to the conver- 
sation given above, but contents himself with saying, " Mackenzie 
was entrusted (!) with the removal of portions of the tumor."* as if 
my colleagues had graciously waived their rights in my favor, or as 
if I were the handy craftsman to carry out the behests of my scientific 
superiors. The insinuation thus subtly conveyed has absolutely no 
foundation in fact. My colleagues had not taken the very first step 
toward establishing their diagnosis on a scientific basis, nor appar- 
ently had they even thought of so doing. f The proposal came from 
me, and it was only after they had acknowledged their inability to 
carry it out, that I undertook to make the attempt, I must be 
excused for dwelling a little on this point, for it was from this cir- 

* Die Krankheit Kaiser Friedrich des Driiten, p. 9. 

t It was only on reading the German pamphlet that I learned that Dr. Gerhardt had, as a 
matter of fact, made several ineffectual attempts to remove a portion of the growth with snares and 
sharp spoons. This is admitted in the document in question (p. 2), but Prof. Gerhardt carefully 
refrained from mentioning it to me at the time. 



io6 CASE OF EMPEROR FREDERICK HI. 

cumstance that the jealousy of my German colleagues, which subse- 
quently led to so much unpleasantness, first took origin. 

My First Operation. 

Having, as I have already said, no knowledge of the nature of 
the case before I arrived in Berlin, I had left home unprovided 
with any instruments beyond those required for a simple laryn- 
goscopic examination. After the consultation, therefore, I visited 
the shop of the principal surgical instrument maker in Berlin ; but, 
although he had sold many of my own laryngeal forceps, he did not 
happen to have any in stock. This was a great disappointment to 
me, for every surgeon knows what a difference there is between 
operating with an instrument familiar to his hand and one to which 
he is unaccustomed. I found a forceps, however, of a French pat- 
tern with which I determined to make the attempt. Meanwhile 
the Prince and Princess had returned to Potsdam, and I was left 
alone in the Kronprinz Palais with leisure to think over the whole 
situation, and in particular of the operation which I was to perform 
the next morning. It was trifling enough in itself, and I had done 
it with success on several hundred patients, but never in a case so 
fraught with momentous issues. I had an instrument the blades of 
which were only half the size of mine ; besides, only the front 
blade moved, whereas I was accustomed to a forceps in which both 
blades opened. If I failed — and failure was not unlikely — my 
colleagues, whose jealousy was already alarmed, would be sure to 
make the most of it, and, what was far worse, the illustrious patient 
would be subjected to a grave operation, which was possibly unnec- 
essary. If, on the other hand, I succeeded, what would Prof. 
Virchow's report be as to the nature of the growth removed ? 

It must be borne in m.ind that the extraction of a growth from 
the larynx with forceps is an altogether different matter from 
attempting to burn it away with the cautery. In the former case 
the operator either succeeds or he fails, and his success or failure is 
at once evident not only to the bystanders but to the patient. The 
manipulation is one which requires no ordinary degree of skill, and 
the operator's movements are guided, not by direct vision, but by 
an image of the parts he is attacking reflected on a little mirror 
which he has to hold in the throat with one hand whilst he wields 
the forceps with the other. With the cautery a great moral impres- 
sion may be produced without any corresponding physical execu- 
tion, or the burning may be effected in the wrong place without the 
patient being aware of the fact. I was, therefore, about to attempt 
an operation of extreme delicacy under circumstances calculated to 



DR. MACKENZIE'S REPORT. 107 

tax my nerve to the utmost ; and there would be no possibility of 
concealing or explaining away a failure. 

Early on the following morning (May 21) all the doctors 
assembled again in the palace. As the room in which the operation 
was to take place was rather small, Dr. Wegner suggested that, 
besides himself, only the two physicians (Gerhardt and Tobold) who 
could use the laryngoscope, should be present. Cocaine was then 
applied to the Crown Prince and everything was got ready. Whilst 
we were waiting till the local anaesthetic had produced its effect, 
some one knocked at the door. Dr. Wegner left the room and 
almost immediately returned, bringing Prof, von Bergmann with 
him. He observed that he was not previously aware that the pro- 
fessor was a laryngoscopist, but as he now claimed to be so he was 
admitted into the somewhat crowded room. When the cocaine 
had taken effect, I introduced the forceps into the larynx, but failed 
to seize the growth. As a rule I do not introduce the forceps more 
than once at the same sitting, but in this instance, as I was working 
at some disadvantage with an unfamiliar instrument, I determined 
to try again. I did so, and this time was more successful. On 
withdrawing the forceps and opening the blades (which are hollow 
01 the inside like spoons), there was a fragment of growth in one 
of them, which I showed to those looking on. I saw a look of 
amazement, quickly followed by one of annoyance and disappoint- 
ment, come over the faces of Profs. Gerhardt and Tobold ; Dr. 
Wegner, on the other hand, seemed delighted, and warmly con- 
gratulated me. After the operation, Prof. Gerhardt made a laryn- 
goscopic examination, and said he could see that the fragment 
which I had removed had been taken from the posterior and under 
part of the growth.* It was at once placed in spirit by Dr. Weg- 
ner, and given by him into the hands of Prof. Virchow. The 
appearance of the growth after my operation is shown in Fig. 2. 

* In his recent report Prof. Gerhardt gives a different account of the matter. He says (Op cit., 
p. 9), " I saw a small loss of substance in the mucous membrane on the upper surface of the left 
vocal cord near the external border of the tumor." Although Dr. Gerhardt has for some reason 
modified his opinion as to the exact spot from which the fragment was taken, there can be no 
doubt that wherever it came from it was diseased, not healthy, tissue. This was acknowledged 
by Gerhardt at the time. 



io8 CASE OF EMPEROR FREDERICK III. 




Fig- 2. — Sketch of growth after first operation. Sketch made May 22. 
(See Explanations, Fig. i, p. 104.) 

At Potsdam with my Imperial Host. 

After the operation the Prince returned to Potsdam, where he 
graciously invited me to stay with him, adding, "You can go into 
Berhn every day for some hours if you find it dull." In the after- 
noon I went to Potsdam, where I had the honor of driving out 
with their Imperial Highnesses and the three Princesses in a wagon- 
ette. On the following day I accompanied the Imperial family to 
Bornstadt, where I was shown the model farm which supplied them 
with milk, butter and eggs. Whilst staying at the Neue Palais 
(now Friedrichskron) I visited the picturesque church and church- 
yard, both of whii h gave ample evidence, by their condition, of the 
interest taken in them by their Imperial Highnesses. I was particu- 
larly charmed with the creche, or children's nursery, established in 
the village by the Crown Princess ; the children, between twenty 
and thirty in number and ranging from a few months to five or six 
years in age, looked healthy and happy, and the whole appearance 
of the place and its inmates bore eloquent testimony to the foster- 
ing care of the Princess. 

The Prince and Dr. Gerhardt. 

The Princesses drove home, but I had the privilege of walking 
back to Potsdam with the Crown Prince, who took the opportunity 
to speak to me very seriously as to his condition. He told me that 
a friend (he did not mention whether it was a lady or a gentleman) 
met him at Ems and said to him, "I was going to call on you, for I 
am grieved to hear that Gerhardt says you have cancer." His 
Imperial Highness asked me if I did not think Prof. Gerhardt had 
done wrong in sending him to Ems if he believed him to be suffer- 
ing from cancer I rephed that I had assuredly never heard of the 
Ems waters doing good in a case of cancer, but I ventured to sug- 
gest that possibly the physician had been misrepresented. The 
Prince then asked me if it was usual for medical men to mention 



DR. MA CKENZIE ' S REPOR T. 109 

that a patient was suffering from cancer to outsiders, or, as he 
expressed it, to "other people," "when the patient's own wife" 
was not told of it. I again took the liberty of pointing out that 
Prof. Gerhardt might be able to give a satisfactory explanation of 
the matter if it were brought under his notice. His Imperial High- 
ness seemed extremely dissatisfied with Gerhardt, not only for his 
indiscretion in talking about the case, but for having sent him to 
Ems though believing him to be suffering from malignant dis- 
ease. He then changed the subject, and among other things we 
talked of the scenery. I expressed great admiration of the land- 
scape at Wildpark, which, I said, reminded me of an English park. 
The Crown Prince thereupon said that next to Germany he pre- 
ferred England, and especially Scotland for scenery. He spoke 
with the keenest delight of the beauties of nature, for which he 
evidently had a most appreciative eye. More than once, however, 
during our walk, the Crown Prince reverted to the Ems incident, 
and though naturally reserved about himself, he could not help 
showing that Prof. Gerhardt's indiscretion, even more than his want 
of medical judgment, rankled in his mind. In the course of our 
conversation, I asked the Prince if it was true as commonly 
reported that he had been a great smoker. He told me that like 
many other reports it was quite untrue, and that for many years he 
had hardly smoked at all. He said that when campaigning he had 
sometimes solaced himself on a fatiguing march, or after a hard- 
fought battle, with a pipe, and he had been seen doing this by a 
great number of his troops, who probably afterward talked about it. 
In this way the Prince said he supposed that his perfectly unde- 
served reputation as a devotee of tobacco had become established. 
The Crown Prince, though hardly ever out of uniform in BerUn, 
was often in plain clothes whilst staying at his palace at Wildpark. 
I was greatly struck by the genial courtesy of his bearing to the 
peasants whom he met ; instead of a perfunctory nod or a careless 
wave of the hand, he returned their salute by taking off his hat, as 
an ordinary Englishman does in saluting a lady. It was easy to 
see that the stately Kronprinz was " Unser Fritz " in the hearts of 
the lowliest among his future subjects. 

'What I had Prevented. 

In the course of a walk, in which the Crown Princess was good 
enough to invite me to accompany her, she informed me that before 
my arrival it had been determined to perform an external operation 
on the Crown Prince. This was fixed to take place at 7 a. m, on 
Saturday, May 21. An operating-table had been brought from the 
Charite hospital, and two nurses were already in the palace. Her 



no CASE OF EMPEROR FREDERICK III. 

Imperial Highness said that it had been Bergmann's intention to 
open the larynx in the middle line in front,* so as to see the extent 
and connections of the growth with a view to its complete removal 
if feasible. In fact, as her Imperial Highness observed, " it was to 
be an exploratory operation ; but when once begun, it was quite un- 
certain where it would end." These statements are confirmed by 
Prof, von Bergmann himself,! who affirms, moreover, that he had all 
the risks of the proposed operation and its probable results clearly laid 
before the Prince. From what he says, however,^ it is easy to gather 
that he gave the Prince a highly optimistic view of his prospects, 
especially in the matter of voice. I have the best reason for be- 
lieving that it was not till several months later, when the Crown 
Prince was at Braemar, that he learned quite accidentally from one 
of his gentlemen-in-waiting the formidable nature of the operation 
which had been almost forced on him in May. 

It has often been privately insinuated, if not openly stated, that 
the illustrious patient was never informed as to the true nature of 
his disease — that, in fact, he was buoyed up with false hopes. The 
truth, however, is that Gerhardt's gossip about the case brought a 
knowledge of its serious nature to the Prince's cognizance at a very 
early period. Although, for the sake of his family, he manfully as- 
sumed a cheerful demeanor, the horrible idea that he was the sub- 
ject of cancer must have frequently occurred to him. 

Virchoisfs First Report. 
Prof. Virchow s report was of course awaited with the keenest 
anxiety, for on it depended the course to be pursued. Two days 
after the removal of the fragment, Dr. Wegner informed me that the 
great pathologist had failed to find any evidence of malignancy, but 
would like to have a further piece for examination. Dr. Wegner 
afterward told me, however, that Prof. Virchow was perfectly satis- 
fied with the result of his examination, and did not require any more 
of the growth. Subsequently a report was received from Prof. Vir- 
chow in which he pronounced the portion of growth which had 
been submitted to him to be of benign nature. He stated that the 
epithelial cells were increased in number and size, and added, that 
as the section had penetrated through the whole thickness of the 
growth down to the tissue of the vocal cord (as shown by the pres- 
ence of longitudinal elastic fibres), there was no reason to suppose 
that the remainder of the growth was different in structure from the 
portion which he examined. This report is unfortunately not pub- 

* An operation called by the Gvcitv3LXi% Laryngofissjir, and in this country, generally, thyrotomy. 
t Oj> cit. 
J Ibid. 



DR. MACKENZIE'S REPORT. iir 

lished in the German pamphlet, though it is deposited among the 
" official sources " on which that document professes to be based. 
I may here mention that I applied to the Haus-Ministerium, through 
Count Radolinski, in December, 1887, for copies of the various 
documents relating to the Crown Prince's illness which had been de- 
posited in the State Archives, but my request was positively re- 
fused — for what reason I am at a loss toconjecture. According to 
Prof. Gerhardt, however, who has had access to all the papers, Vir- 
chovv's examination showed only an " irritative process ; but there was 
an isolated nest of concentric epithelial cells (a cell-nest in fact) in 
the midst of proliferating epithelium."* Virchow declared verbally 
at the time that the affection might be a pachydermia laryjigis^ — a 
thickened, warty condition of the larynx resulting from chronic in- 
flammation. This report conclusively proves that whatever the affec- 
tion from which the Crown Prince was suffering might be, the tissue 
which I removed was not healthy tissue (as has been suggested), 
but one presenting a warty character. It is simply inconceivable 
that the first pathologist in the world should mistake healthy for 
diseased tissue, and it is incredible that such a man should, under 
any circumstances whatever, have lent himself to any wilful de- 
ception. 

My Second Operation. 

On May 22 I found the left ary-epiglottic fold and the left vocal 
cord, together with the whole of the rigid one, a good deal con- 
gested. The voice was slightly hoarse. During the day it became 
clear, but toward night it was husky. In the evening I observed 
that though the anterior half of the right vocal cord had become 
almost normal in color, the middle third was bright red; there was 
also still some slight congestion of the left ary-epiglottic fold. 
The congestion appeared to me to be of a catarrhal nature, and as 
the Crown Prince at that time did not take much care of himself, it 
was supposed that he had caught cold. I should mention that this 
tendency to the sudden development of localized congestion in the 
larynx was subsequently noticed by Dr. Wolfenden, Mr. Mark 
Ho veil, and Prof. Krause, as well as myself, as a peculiar feature | 
in the Crown Prince's case. On May 23, in the presence of Prof. 
Gerhardt and Dr. Wegner, I made a second attempt to remove a 
piece of the growth from the larynx. Before introducing the for- 
ceps. I examined the throat, and found the larynx in much the same 
state as on the previous evening. 

* op cH., p. q. 
f Ihid. 

\ There is every reason to believe that this abnormal irritability vifas due to the extraordinary 
mode in which Gerhardt had burnt the larynx. (See page 123.) 



112 CASE OF EMPEROR FREDERICK III. 

This time I did not succeed in bringing anything away with the 
forceps. I did not pass the instrument far enough down, and the 
blades closed before they were in contact with the growth. In this 
kind of work the operator knows when he has seized what he is 
aiming at, just as an angler feels when he has a "bite." There was 
no resistance, and I was sure before I withdrew the forceps that the 
blades would come up empty. In view, however, of the conges- 
tion to which I have alluded, I thought it well not to run the risk 
of irritating the larynx by any further manipulation on that day. 

Gerhardf s False Accusation. 

An occasional failure of this kind, as every laryngologist of any 
experience knows, is so common that I attached no importance 
whatever to the incident, and should certainly not have thought it 
worth mentioning had it not been for some remarkable events 
which followed. When I had laid aside the forceps, saying I 
would not again use them at that sitting. Prof. Gerhardt asked to 
be allowed to examine the larynx. He had scarcely put the mirror 
in position when he withdrew it with a highly artistic expression of 
horror and alarm. He asked me to look, which I did, but without 
seeing anything more than the congestion of which I have spoken, 
which was perhaps rather more marked on the right vocal cord. 
Gerhardt then asked Wegner to look, but that gentleman did not 
see anything in particular.* We then retired to my room, when Dr. 
Gerhardt said that I had wounded the right vocal cord. He was 
considerate enough to add that if symptoms of suffocation should 
follow this injury, there was a clever surgeon in Potsdam who would 
be able to perform tracheotomy. I assured the professor that 
his fears were quite groundless, and showed him that with my t for- 
ceps it would be difficult, if not impossible, to wound a healthy cord, 
even if one tried to do so.| The blades would cut away anything 
projecting from the cord, but not a smooth surface like that of a 
healthy vocal cord. My forceps act very much like the shears used 
for clipping hedges, supposing them to be blunt-pointed. With 
such an instrument a man standing sideways at a wall might cut off 
twigs or weeds projecting from it, but it would be impossible for him 
to shear off anything that did not stick out from the flat surface. 
As a matter of fact, so incapable is my instrument of seizing any- 

* This, though I might claim it as testimony in my favor, I do not attach much importance to, as 
Dr. Wegner was seldom able to obtain a good view of the interior of the laryn-x. 

t I had by this time had my own instrument brought over to me. 

* Prof Gerhardt states, op cit., p. 9, that on his mentioning the matter to me, I expressed my- 
self in the following remarkable terms, " It can be " I do not pretend to know what these words 
may mean, but English readers will liave no difficulty in believing that I never could have used 
them. The matter is trivial in itself, but affords a useful gauge of my accuser's accuracy in more 
serious things. 



DR. MA CKENZIE ' S REPOR T. 113 

thing that does not project, that in the case of very small growths I 
do not attempt their removal. I never try to remove a growth 
smaller than a split tare from the vocal coid because my instrument 
does not act unless there is a certain amount of projection to come 
between the blades. Had Prof. Gerhardt said I had wounded the 
epiglottis, or one of the capitula Santorini, which present projections 
and edges, so placed that they could be seized, the accusation 
would have been less improbable — that is to say, an exceptionally 
clumsy person might accomplish the injury attributed to me. A 
wound of such severity as that described by Prof. Gerhardt could 
hardly have been inflicted without the patient's suffering some in- 
convenience from it afterward. After the effect of the cocaine had 
passed off there would have been smarting at the seat of injury, a 
very uncomfortable feeling in the throat generally, great irritation 
in the larynx, leading to coughing, and perhaps even a tendency to 
spasm of the glottis. Not one of these symptoms was present. 
Above all, there would have been the objective symptoms of blood 
being coughed up. 

The professor tells us of a large clot of blood sticking out of the 
wound into the glottis. How was it that none of the fresh blood 
had been expectorated ? Perhaps it is as well to remind my readers 
that I was now operating with my own forceps, and that / did not, 
because I actually could not, wound the right vocal cord. Although, 
according to Prof. Gerhardt, Dr. Lahdgraf reported that this sup- 
posed wound did not heal until June 29, the young Stabsarzt was 
no doubt on the alert for the phantom lesion about which his chief 
had given him useful hints (informationen)* The description of 
the healing of the imaginary wound gives a touch of local color, no 
doubt highly gratifying to the professor. Dr. Wolfenden reported 
on June 15 that "the right vocal cord is healthy." Dr. Wolfen- 
den's testimony is all the more valuable, because I had given him 
no " hints." Indeed, so little thought had I given to this childish 
complaint of Gerhardt's, that after mentioning it to one or two 
friends on returning from Potsdam, I had never thought of it again. 
I had never for a moment dreamt of its being made a serious charge 
derived from " official sources ! " I have operated many thousands t 
of times, and many of the leading laryngoscopists of this country 
and of America have at one time or another seen me operate. Not 
one of them, I am sure, can say he has ever witnessed any accident 
of the kind befall me. More than this. When I gave more time 

♦These "hints" ceased, it seems, as soon as Landgraf was appointed my "controller," but as 
they had already been given, there was no occasion for their continuance (see foot-note, p. 13s) 

t I have notes of over 400 cases, and on an average these would be operated on, successfully or 
otherwise, at least 10 times each, so that, at the lowest computation, I must have introduced the 
forceps 4,000 times. 



114 CASE OF EMPEROR FREDERICK III. 

to teaching than I can do now, I used to allow my pupils to operate 
with my forceps when they had worked with me for a year. 
Though I have, of course, often seen them fail to get anything 
away, I have never once heard of any injury being inflicted, even by 
the rawest hand. I pointed out, moreover, to Prof. Gerhardt that 
if by some quite exceptional stroke of ill-luck such an out-of-the-way 
accident had occurred, it was really not a matter of the slightest con- 
sequence, as it was well known that wounds of the vocal cords healed 
in a few days. This is seen after the removal of growths, when in 
order to extirpate the new formation thoroughly, it is often necessary 
to cut into the healthy substance below it. No ill effect of any kind 
is ever known to follow. 

There can be no difficulty in understanding Prof. Gerhardt's. 
motive in the affair. My success on the first occasion had mortified 
him, and he was glad of an opportunity to find fault. Operations 
on small sessile growths, such as I had to deal with in the present 
case, are often unsuccessful, and I should not have been surprised 
if I had had to make a dozen attempts before succeeding. As a 
matter of fact my operations on the Crown Prince were quite excep- 
tionally successful, for in four attempts there was only one failure. 
This proportion of successes is quite outside the ordinary experience 
of the deftest operators, and I cannot help feeling that good luck 
played as important a part as skill on these occasions. But whether 
I had failed or succeeded, it wa% hardly professional on the part of a 
colleague to endeavor to damage me in the eyes of my patient by 
a carefully prepared coup de theatre such as I have described. Even 
if I had inflicted the injury imputed to me, I say the conduct of Prof. 
Gerhardt on that occasion would have been unfair both to the 
patient and to me. Half an hour after Dr. Gerhardt had left, the 
Crown Prince sent for me, and said, " Did any accident occur dur- 
ing your operation, as Prof. Gerhardt looked so very much alarmed ? "- 
The Prince added, " My throat feels quite comfortable." I replied 
that I thought Prof. Gerhardt was under some misapprehension, and 
that in any case the matter was of no consequence. His Imperial 
Highness said nothing more, and I clearly saw that the plot had 
failed so far as the patient was concerned. 

Gerhardt keeps up the Farce. 

Two days later we had another general consultation at Berlin, and 
here again Prof. Gerhardt's dramatic talent displayed itself. Lower- 
ing his voice to a tragic whisper, he asked me whether he might be 
permitted to communicate " a certain event" to the assembled doc- 
tors, adding significantly, " We are among colleagues, and with 
closed doors." Guessing that his mysterious allusion had reference 



DR. MACKENZIE'S REPORT. 115 

to my supposed accident, I begged him to be under no restraint, 
and he then proceeded to explain, in an artless, pitying sort of way, 
that 1 had injured the right cord. Prof, von Bergmann was then 
invited to use the laryngeal mirror, and Prof. Tobold followed. 
They both said that they believed the right vocal cord was injured. 
As Prof, von Bergmann had not posed as a laryngoscopist until I 
arrived in Berlin, and as Tobold showed an obsequious willingness 
to re-echo every remark made by Gerhardt, I did not attach any im- 
portance to their statements. I now m.ade a very careful examina- 
tion in order to be quite sure as to how the case stood, but could see 
absolutely nothing beyond the congestion previously described. 
Prof. Gerhardt looked again, and said he could see a vegetation 
already sprouting from the wounded spot, adding, with an amiable 
intention for which I was duly grateful, " It will be interesting to 
observe whether the new growth (!) will prove to be malignant." I 
ventured to point out that the development of • cancer in a wound 
supposed to have been made only two days before would in- 
deed be an event of the greatest interest, as such an occurrence 
would revolutionize everything that was thought to be known in 
pathology. Dr. Wegner hereupon interfered with the remark that 
the discussion was assuming an academic character, and suggesting 
that we should turn our attention to matters of more practical im- 
portance. Before leaving the subject I may remark that, if there 
had really been any injury, Bergmann and Gerhardt would certainly 
have insisted on another laryngoscopist being called to bear witness 
to the mischief; but they, no doubt, had reasons for not taking 
this course. I was asked what mode of treatment I proposed to 
adopt in case I should be unable to remove the growth with forceps. 
I replied that I should then endeavor to destroy the growth by ap- 
plying electric cautery from time to time. On the 25th another con- 
sultation was held, and it was decided that I should endeavor to re- 
move the growth through the mouth, every portion of tissue thus 
taken away being immediately sent to Prof. Virchow. It had pre- 
viously been agreed that in the meantime an astringent and sedative 
powder should be applied by Dr. Wegner, in order to get rid of the 
congestion and relaxation of the larynx. These conditions, how- 
ever, proving rather obstinate, I did not consider it advisable to 
make any further attempt at that time. I accordingly started for 
England on May 29. 

Statement of my Position. 

Before concluding this chapter, I think it well to define, with the 
utmost possible clearness, the exact position which I took up with 
reference to this most difficult case. This is the more necessary, in- 



ii6 CASE OF EMPEROR FREDERICK III. 

asmuch as my attitude has been misunderstood and misrepresented 
to an extent almost without precedent in medical practice. I re- 
peat that I gave no opinion one way or the other as to the nature 
of the disease. I did not say that it was not cancer; I only said 
that that opinion was " not proven ; " and in the absence of posi- 
tive proof I refused to sanction surgical procedures which at pres- 
ent are at the best more or less of the nature of experiments, which 
are always dangerous to life, nearly always destructive to the voice, 
and which, even when " successful," too often leave the patient un- 
fit for the business of life, or even sometimes in a condition worse 
than death itself. Till the nature of the case should be clearly proved, 
it seemed to me to be my duty, not merely as a physician, but as a 
man, to oppose the application of a remedy which the patient might 
justly think worse than the disease. 



CHAPTER XV. 



MY SECOND VISIT TO POTSDAM. 



My Third Operation. 

On June 7, I again arrived at Potsdam, in obedience to a sum- 
mons from the Crown Prince. On the following morning I exam- 
ined his throat in the presence of Dr. Wegner, when I found that 
the congestion formerly present had entirely disappeared. I had 
not proposed to operate till arrangements could be made for some 
of my colleagues to be present, but finding the occasion particularly 
favorable, I did not care to let it slip. I accordingly had my 
forceps brought to me from my room at the top of the palace, and 




Fig. 3. — Sketch of growth after the third operation. (For explanation, see 

Fig. I, p. 104.) 

after applying cocaine, succeeded in getting away more th-an half of 
the growth. The tissue removed was at once conveyed by Dr. 
Wegner to Prof. Virchow, and after waiting a day or two for his 
report, a grand consultation was held, in which all the gentlemen 
who were present on the previous occasions took part. The fol- 
lowing report was read : 

Prof. Virchow's Report on the Portion of Growth Removed from the 
Larynx of H. I. H. the Crown Prince of Germany, on June 8, by Dr. 
Morell Mackenzie. 

"The two specimens delivered yesterday by Director-General Dr. Wegner, 
exhibit, on microscopic examination, the appearance of a coarsely granular 
papillated tumor. Their convex surface had a granular, bluish-white, slightly 



ii8 CASE OF EMPEROR FREDERICK III. 

transparent glistening aspect, in so far as they retained their natural conditions ; 
large portions, indeed, which had been acted upon by catechu showed a dull, 
brownish, somewhat crumbling character. The cut surfaces were somewhat 
retracted, and concealed by the turning up of the margins : they consisted of a 
soft, slightly fibrillated tissue, from which projected some shreds of various 
lengths. The larger of the two portions was 3 millimetres in height and had a 
diameter of 2.5 millimetres ; the smaller was about 2 millimetres in diameter. 
Hov ever, these measurements could not have quite corresponded to the 
conditions during life, for by the retraction and infolding of the cut surfaces after 
extirpation, they must have undergone a diminution. Microscopical examination 
confirmed the diagnosis made by the naked eye inspection : — i. The surface 
everywhere consisted of a very firm and thick layer of stratified squamous 
epithelium. Large colloid granules appeared in many of the cells. Here and 
there lay a nest of concentrically laminated cells. Internally there occurred a 
similar stratified layer of cylindrical cells (without cilia), which were seated 
directly on the connective tissue. 2. The connective tissue layer of the 
mucous membrane was furnished on its surface . with long papillary out- 
growths, which contained large vascular loops besides the connective tissue 
elements. Each such papilla corresponded to a granulation on the surface. 
Otherwise the mucous membrane showed scarcely any changes; even pro- 
liferation of nuclei and cells was only sparsely detected. The blood-vessels 
were moderately dilated. Both sections have been made deeply into the 
mucous membrane and through this into the submucosa. Hence there 
are found, besides connective tissue with numerous fine elastic fibres, a 
large number of small nerve trunks (from four to six fibres) and their branches, 
as well as small arteries and veins ; in some places are seen also collections of 
lobules of the mucous glands. Although it is thereby proved that the operation 
had reached the deep parts* underlying the mucous membrane, yet in spite of the 
most careful examination of these deeper parts, especially at the cut surfaces, no 
single portion could be found altered in an appreciable degree. All such changes 
were confined to the surface. They characterize the lesion as an epithelial 
growth, combined with papillary offshoots (misnamed papilloma), pachydermia 
verrucosa. In no part cotild an ingrowth of this epithelial formation into the 
mucous membrane be detected. * 

The foregoing statement is an important advance upon the statement of the 
2ist of May. In the specimen then examined changes resembling those now 
present were only very scanty in comparison with irritative changes; but all 
such appearances were limited to the periphery of the lesion. Now, on the 
other hand, « more ceiitral portion of the growth has apparently been obtained. 
Although this portion is very 7nuch diseased,* yet the healthy condition of the 
tissue on the cut surface allows a very favorable opinion to be formed as to p7'og- 
nosis.* Whether such an opinion would be justified in respect to the whole 
disease cannot be ascertained with certainty from the two portions removed. 
However, there is nothing presefit in them which would be likely to excite the 
suspiciott of wider and graver disease. ''''\ 

Prof. Dr. RuD. Virchow. 

^^ Berlin Pathological Institute, 
June ^th, 1887." 

* None of the italics are in the original. 

t Before leaving Berlin. T suggested to their Imperial Highnesses that in order to allay the 
great anxiety naturally felt by the public it would be desirable to allow Prof Virchow's report to be 
published. The Crown Prince accordingly gave orders that it should be communicated to the 
Berlin medical journals. The translation given above is that which was published in the Lancet 
of June 25, 1887 (p. 1302), of the German text which appeared in the Berliner kUnische 
Wochenschrift. 



DR. MACKENZIE'S REPORT. 119 

It must be borne in mind that Virchow, knowing that his report 
would come under the eyes of the patient, was naturally anxious 
to make it as favorable as he could consistently with the truth. It 
will be observed, moreover, that he was careful to limit his remarks 
to the portions of tissue actually examined by him. Nevertheless, 
when discounted to the fullest extent, the report could not fail to be 
highly encouraging. The fragment had been taken more from the 
centre of the growth than the one first removed, and the section 
had been made quite through the diseased structure into the 
healthy parts beneath it ; it might therefore fairly be accepted as a 
representative specimen of the whole. The essential anatomical 
feature of cancer, viz., the penetration of the epithelium into the 
underlying structures, was conspicuous by its absence. Cancer has 
been not inaptly defined as an itigroiving wart. However thickened 
or otherwise diseased the superficial covering may be — however 
much it may grow ouiivard — so long as it does not force its way 
into the deeper parts, there is no cancer. It is true that the evi- 
dence here was merely negative, and did not positively disprove the 
existence of malignancy, but it made it very improbable. As if to 
emphasize this. Prof. Virchow went a little beyond his strict province 
(which was simply to record what he saw), and said that there was 
nothing in the portion of growth which had been submitted to him 
that gave grounds for suspicion as to the nature of the remaining part. 

The Case is handed over to Me. 

After the reading of Virchow's report, a consultation took place 
among us, the result of which was that, with the unanimous consent 
of those present, the case was handed over to me for treatment in 
the manner I had proposed. My plan, as I have already stated, 
was to attempt to extirpate or destroy the growth by what is known 
as the endolaryngeal method ; that is to say, by instruments passed 
into the larynx through the mouth. If after a fair trial this line of 
treatment was not found to answer, it would have to be considered 
whether an external operation should be performed, and if so what 
kind of operation should be done. On May 25 it had been agreed 
that all portions of growth removed should be submitted to Prof. 
Virchow, and that, in the event of my treatment not proving suc- 
cessful, further deliberations should take place with the view of 
considering subsequent procedures. The exact agreement arrived 
at in the consultations of May 25, and confirmed on June 10, 
between the German doctors and myself, has been absurdly misrep- 
resented. All that I "agreed to " — I may even go further and say 
" advocated" — was first, that all portions of growth which I might 
remove should be sent to Piof. Virchow for his report, and secondly, 



120 CASE OF EMPEROR FREDERICK III. 

that in the event of my failing, other measures should be concerted. 
It was subsequently pretended, though this has not been embodied 
in the German pamphlet, that I had promised to send reports to my 
colleagues from time to time, and von Bergmann goes so far as to 
say * that I agreed, if the tumor increased in size, to allow thyrot- 
omy {Laryngofissur) to be performed. As the exact nature of any 
proposed future operation was never discussed, it will be seen that 
there cannot beany grounds for von Bergmann's contention. That 
there is great confusion in the minds of my German colleagues, as 
to the arrangements made between us, is shown by the fact that 
Gerhardt states that the conditions under which I was to take charge 
of the case were agreed to on June i,t at a consultation held at the 
residence of Dr. Wegner, at a time when I was not present in Ber- 
lin. The conditions agreed to were rigidly adhered to by me. The 
final portion of growth which I removed was submitted to Virchow, 
and when, in November, my treatment proved unavailing, I invited 
two eminent laryngoscopists to meet me in consultation to decide 
what further steps should be taken. 

Under the circumstances no other decision could possibly have 
been come to than that which was come to on May 25. In the 
face of such a report as had been received from the man whose 
supreme authority on such matters is recognized by the whole med- 
ical world, no doctor would have thought for a moment of submit- 
ting to a serious operation if the case had been his own. I can 
certainly answer for myself that, if I had been the patient, I 
should have serious doubts as to the sanity of a surgeon who 
proposed siich a thing. 

My Colleagues share my Responsibility . 
From what has been stated it will be seen that it is quite untrue 
that I took the case out of the hands of the German doctors. They 
had called me in, and I had given my opinion, to which, outwardly 
at least, they had subscribed. They distinctly sanctioned the course 
of treatment which I had laid before them, and, if I may so express 
it, I received a mandate from them to carry it out. Had the case 
turned out well these gentlemen would no doubt have been ready 
enough to claim their share of the triumph on the ground that they 
had "entrusted" me with the operation. It is absurd, therefore, to 
thrust on me the whole responsibility for a decision to which they 
were all consenting parties, simply because the event belied the 
hopes that were not unreasonably entertained. If, in spite of Prof. 
Virchow's report, Bergmann and Gerhardt were convinced at that 
period that the disease was cancer, and at the same time had no 

* op. cit., p. 27. 
t Ibid. , p. 14. 



DR. MACKENZIE'S REPORT. 121 

confidence in me, either as an observer or an operator, the only honor- 
able course toward the patiejit for these practitioners to have pursued v^^?, 
to have openly withdrawn from me, and to have issued a separate 
report. Instead of this they endorsed the resolution which was 
come to with regard to the conduct of the case, hi foro externo at 
least, and thereby contracted a solidarity of responsibility with me. 
The only possible explanation of their conduct, supposing them to 
be honorable men, is that they did not feel at all sure about the 
diagnosis. Further on (p. 242) it will be shown that at the end of 
September or beginning of October, von Bergmann actually ad- 
mitted that I had been right in the course I had recommended in 
the early summer. In showing that the German doctors are equally 
answerable with me, I am not trying to remove any part of the re- 
sponsibility from my own shoulders; I only wish to show the shifty 
character of the men with whom I had to deal. 

The Crown Prince resolves to come to England. 

Another point on which there has been much misrepresentation 
is the choice of London as the place where the treatment should be 
carried out. When it was settled that I should try to get rid of the 
disease by operating through the natural passages, I was asked if I 
could stay at Potsdam for the purpose, and I pointed out that there 
were many objections to this. The Crown Prince was extremely 
anxious to be present at the Queen's Jubilee, and I need hardly say 
that it was more convenient for me to treat him in London, where 
I had all the necessary appliances ready to my hand, than in the 
somewhat haphazard way I had been doing in the palace. His 
Imperial Highness's visit to England had been arranged several 
months before, and, therefore, the suggestion that the treatment 
should be carried out in London, harmonized with his own plans. 
I agreed, however, to go to Potsdam if circumstances should (as 
was not improbable) arise which would make it difficult for him to 
leave Germany. 

More Gerhardtian Ajnenities. 

I have already mentioned my experience of Prof. Gerhardt as a 
"candid friend;" I had now to learn his powers as an unscrupulous 
foe. Before I left Potsdam, the Crown Princess told me that Prof. 
Gerhardt had said to her, that even if I did succeed in cutting away 
the growth with forceps, the healing or cicatrization of the wound 
would so interfere with the working of the vocal cord that, as far as 
the voice was concerned, the last state of the illustrious patient 
would be worse than the first. The professor also gave her to under- 
stand that the right vocal cord was in a festering condition, owing 



122 CASE OF EMPEROR FREDERICK III. 

to the injury I had caused! I assured the Princess that these 
alarming statements were absolutely unfounded. With regard to 
the cicatrix, I said I had cured hundreds of cases without any such 
ill consequence as Prof. Gerhardt professed to fear in the present 
instance. As for the alleged "suppuration" of the right cord, I 
was obliged to confess that I had no idea what was meant. After 
this illustration of Prof. Gerhardt's peculiar notions of professional 
eihics, I was compelled to inform the Crown Princess that I must 
in future, decline to meet him again in consultation, though I had 
no wish to interfere with his examining the Crown Prince's throat 
as often as His Imperial Highness might desire. 

Gerhardt appoints a '■''Cojitr oiler ^'' 

What finally opened my eyes to the kind of treatment I had to 
look for from my German colleagues was the underhand way in 
which, on pretence of providing the Crown Prince with surgical 
help in case of emergency, I was to be watched, or, as Gerhardt 
now says, " controlled." * The professor had hoped to accompany 
His Imperial Highness to England; but as there seemed to be no 
necessity for this under the circumstances, it was arranged that Dr. 
Wegner should look after the illustrious patient's general health 
whilst I conducted the special treatment. Had it been openly inti- 
mated to me that it would be more satisfactory to the German 
Court, if the Crown Prince were also accompanied by a competent 
German laryngoscopist to report from time to time on the progress 
of the case, I should not have raised any objection. Instead of this, 
I was informed by Dr. Wegner, that by desire of the Emperor 
William, a young army surgeon {Stabsarzt) would go to England as 
his (Dr. Wegner's) assistant. His words were : " My eyes are not 
so good as they were, and it would be convenient to have a young 
surgeon with me in case tracheotomy should become necessary." 
It was only by accident that I discovered that Dr. Landgraf — the 
Stabsarzt in question — was one of Prof. Gerhardt's assistants. This 
fact I learned from a well-known throat- speciahst in Berlin, on whom 
I happened to call before leaving Berlin. This gentleman, moreover, 
told me that Dr. Landgraf was anything but a skilful laryngoscopist, 
and had, only a few weeks before, been unable to distinguish the true 
from the false vocal cords. I afterward had ample opportunities of 
seeing for myself how thoroughly the young Stabsarzt deserved his 
reputation in this particular. I shall deal with Dr. Landgraf's so- 
called " observations " further on. 

*Op.cit., p. 14. 



DR. MACKENZIE'S REPORT. 123 

The Artificial Production of Cancer. 
I must here make a few remarks on a subject which I should have 
Ijeen glad to avoid, viz., the influence of Prof. Gerhardt's treatment 
on the nature of the malady from which the illustrious patient suf- 
fered. The fact, however, that Prof. Gerhardt has himself raised the 
question in his recent publication as to how far his own treatment 
was responsible for the unfavorable course of the illness, makes it 
impossible for me to pass over this subject. 

Before returning to England I learned, on unimpeachable authority, 
certain facts as to Prof. Gerhardt's previous treatment of the case, 
which made me feel more anxious about the future than I had up till 
then seen any reason to be. I have already said that the professor 
liimself had touched on the matter very lightly in my presence, and 
when he mentioned in general terms that he had used the galvano- 
•cautery, I naturally understood him to mean that he had employed 
this powerful agent according to the recognized rules of surgical 
practice. When, therefore, I was informed that he had applied the 
Ted-hot point to the interior of the larynx every day for nearly a fort- 
night I could hardly bring myself to believe it. In all my experience 
I had never heard of any one applying the cautery to a patient's 
larynx oftener than once, or at most twice a week, and I hardly 
tnow which to be the most astonished at in the present instance, the 
therapeutic energy of the physician or the endurance of the patient. 
Lest any of my readers should suppose that I had been misinformed, 
or at any rate that the statement just made was exaggerated, I may 
say that it is now confirmed by Prof. Gerhardt himself in his recent 
deliverance.* 

Now no special knowledge is required to understand that a deli- 
cate organ like the larynx cannot be brutalise in this manner with 
impunity. The fact that the Crown Prince had been subjected to 
such barbarous usage at once explained the proneness of the parts 
to become congested without any apparent cause, which had pre- 
viously rather puzzled me. Every one knows that local inflamma- 
tion follows an accidental burn, and there is no special sanctity 
about a similar injury inflicted by a surgeon which prevents its being 
followed by the natural consequences. It is for this very reason, 
that a sufficient interval should always be allowed to elapse between 
the applications of the galvano-cautery. No point in pathology is 
better established than the connection between local irritation, or 
chronic structural changes induced thereby, and the development 
ot cancer. Whether this terrible disease be constitutional or not in 
its origin, there can be no question that the determining cause of 
its appearance is in very many cases an injury (as a blow), or a con- 

*Die KrankfieU Kaiser Friedrick des Dritten, p. 3. 



124 CASE OF EMPEROR FREDERICK III. 

dition resulting from an injury (as a scar), or the persistent applica- 
tion to a particular spot of something that keeps the tissue inflamed 
and "angry" (such as a jagged tooth which chafes the tongue). 
Workers in paraffine and petroleum are particularly liable to cancer of 
the parts which are habitually exposed to the action of these sub- 
stances. It is well known that a particular form of cancer, which 
formerly was common enough in England, is now almost extinct,* 
simply because, owing to the fact that the cause which produced it 
has ceased to exist. When soot commanded a good price, it had to 
be sifted ; this operation necessarily involved a great deal of fric- 
tion against the skin, whereby irritating particles were, as it were, 
rubbed into it, and "chimney sweep's cancer" was a frequent re- 
sult. Nowadays it does not pay to sift the soot, and the disease to 
which it gave rise has disappeared. 

Among causes of local irritation, heat is certainly one of the most 
active. By far the most common seat of malignant disease in men 
is the mouth, which is more exposed than any other part of the body 
to irritation by hot substances. Every surgeon is familiar with this 
fact. Whether it be a lower lip on which the hot stem of a clay 
pipe or the smoldering paper of a cigarette has rested day after day ; 
or a tongue exasperated by the frequent contact of acrid tobacco- 
smoke, or the mouthpiece of a foul pipe, or made raw by ardent 
liquors, or stung and blistered by fiery condiments, the cause is es- 
sentially the same, viz., the searing or irritation of the superficial 
covering by prolonged heat or pungent impressions. In Cashmir, 
where hot brasiers are often applied to the abdomen and thigh, can- 
cer of these parts is not uncommon,! though all but unknown in 
either of these situations elsewhere. 

It is highly probable that in addition to the local irritation some 
particular predisposition must exist in the patient, though in what 
this consists we do not know. That in a large number of cases the 
tendency to cancer is hereditary, there can be no question ; and the 
truth of this would, I am convinced, be much more evident than it 
now is if the medical histories of families, as well as of individuals, 
were carefully inquired into and accurately recorded. Most men 
know what their father and mother died of ; a large number are ac- 
quainted with the cause of the death of their grandfathers and 
grandmothers, but how few have any accurate knowledge as to the 
nature of the disease which carried off their great-uncles and great- 
aunts. This important and interesting subject cannot be pursued 
here, but it may be remarked that we know quite enough of the 

*Erichsen: Science and Art of Surgery, th edition, London, 1888, vol. I , p. 1048. 
t Sir James Paget : " Morton Lecture on Cancer and Cancerous Diseases," British Medical 
"jfcnirnal, Nov 19, 1887, p. 1093. 



DR. MACKENZIE' S REPORT. 125 

subject to enable us to say that where there is a history of cancer in 
a man's family, it would be well for him to avoid all causes of local 
irritation with especial care. Such a history existed in the case of 
the Crown Prince on the maternal side, for his mother's sister died 
of cancer, and his cousin. Prince Frederick Charles, had a malignant 
tumor removed from his face a year before his death, which did not 
recur, but might very likely have done so had he lived longer. 

Now Prof Gerhardt himself tells us that at a very early period of 
his connection with the case he suspected that the affection was 
malignant. This makes the manner in which he proceeded to deal 
with it simply incomprehensible, except on the supposition that his 
very anxiety made him reckless. It is certain that if the growth was 
not malignant from the first, Gerhardt, by his unmerciful use of the 
galvano-cautery, went the surest way to work to make it so. I do not 
say that he actually caused the cancer ; no one has the right to dog- 
matize in medicine, which is still an inexact science in which nearly 
every fact is open to more than one interpretation. I do not hesitate, 
however, to say that the treatment adopted by Prof. Gerhardt was 
at once unscientific and injudicious. He cannot escape from this 
dilemma : Either his treatment was too thorough, or it was not 
thorough enough. If he believed the growth to be benign, the re- 
peated burning to which he subjected it was barbarous ; if, as he 
says, he was doubtful as to its nature, that very doubt should have 
stayed his hand, and have led him to invoke surgical aid much 
sooner than he did. On twelve consecutive days, according to his 
own admission, did this physician burn the Crown Prince's larynx 
with a red-hot wire, and again on four subsequent occasions at short 
intervals. Finally, as if all this were not enough, he thought it neces- 
sary to sear the edge of the vocal cord with a flat burner ! There is 
no record in medical literature, so far as I am aware, in which the 
cautery, a most valuable agent if properly handled, was so terribly 
misused. 

Some statistics have lately been collected which clearly prove* 
how rarely a benign growth becomes mahgnant, either spontaneously 
or when the ordinary recognized methods of treatment are pursued. 
What different statistical results would be forthcoming, if the method 
of treatment pursued by Gerhardt were widely practiced ! Whether 
his ruthless cauterization actually caused the development of the 
cancer or not, there can be little doubt that he is largely responsible 
for the perichondritis which played so important a part in this sad 
case. Although the inflammation of the cartilage did not show itself 
till some time afterward, it is well known that the course of this 
affection is very slow, and at first extremely insidious. The processus 

* CetitrdlblaitfiirLaryngologie, &"€., Juli. 1888. 



126 CASE OF EMPEROR FREDERICK III. 

vocalis, which was the first seat of the perichondritis in this case, is a 
point where the mucous membrane itself forms almost the sole cover- 
ing of the cartilage. Hence the spot which was the object of Ger- 
hardt's misdirected energy is one that is peculiarly vulnerable. 

To sum up : If the growth was benigti in the first i?istance, there is^ 
in my opinioji, only too much reason to think that Gerhardfs burnings 
must be held answerable for its subsequent transformation into cancer ; 
if it was malignant from the first, the disease was undoubtedly aggra- 
vated by the treatment. 



CHAPTER XVI. 



THE CROWN PRINCE IN ENGLAND 



The Crown Prince ifi the Jubilee Procession. 

On June 14 their Imperial Highnesses arrived in England. 
With the view of sparing the illustrious patient the fatigue of talking 
more than was prudent in his condition, it had been arranged that 
he should stay at some quiet place outside London, and take no 
part in the Court festivities beyond appearing on a few of the more 
important ceremonial occasions. Accordingly he took up his resi- 
dance at Upper Norwood. I need not recall the impression made 
by his splendid appearance as he rode through the streets of Lon- 
don on June 21 in the Queen's body-guard of Princes; he was the 
most striking figure in that historic pageant, and was hailed by the 
enthusiastic crowd as a King of men by gift of nature as well as by 
right of birth. Few could have thought, on seeing him then, in 
the very prime of his magnificent manhood, that behind the hero 
of Koniggratz, Worth and Sedan, there rode on that day of tri- 
umph a grimmer conqueror, who, before another year had passed, 
would have laid that stately form in the dust. 

On the day of His Imperial Highness's arrival at Norwood I 
made a careful examination of his throat, and found that only a 
small portion of the growth, not more than one-third of its original 
bulk, now remained. The little tumor itself was red, but the mucous 
membrane immediately surrounding its base was almost natural in 
color ; there were, however, scattered patches of hypersemia in 
different parts of the larynx. This slightly unhealthy condition of 
the lining membrane of the larynx, which, as I have already pointed 
out, was probably the result of the severe burnings by Gerhardt, 
caused the Prince to catch cold on the slightest exposure. 

Dr. Norris Wolfenden. 

Before the Crown Prince's arrival, I had informed Count Rado- 
linski that when His Imperial Highness came under my care, all 
local treatment would have to be carried out either by myself or by 
some competent specialist thoroughly acquainted with my methods. 
To this the illustrious patient at once consented, but considerable 



123 



CASE OF EMPEROR FREDERICK III. 



opposition was raised by Dr. Wegner, who said that Dr. I.andgraf 
had accompanied His Imperial Highness for that very purpose. I 
reminded Dr. Wegner that he himself had told me that Landgraf 
was sent expressly that he might be at hand if tracheotomy became 
suddenly necessary; that the young man had been described to me 
simply as a military surgeon, and that I knew nothing of his ability 
as a laryngoscopist. Under these circumstances, I said it would be 
impossible for me to accept the assistance of Dr. Landgraf in car- 
rying out the details of ray proposed line of treatment, and I 
requested that my colleague, Dr. Norris Wolfenden, one of the 
Physicians to the Hospital for Diseases of the Throat, should be 
associated with me in the capacity of resident medical attendant on 
the Crown Prince. This was agreed to, and Dr. Wolfenden accord- 
ingly took up his residence at Norwood. On June 15 I received 
from him the following report: "The larynx is large and well 
formed, but, owing to the slope of the epiglottis, the view of the 
interior of the laryngeal cavity is not so easy to obtain as it is in an 
average case. The under surface of the epiglottis is slightly con- 
gested on the right side, and the cushion is rather full. The left 
ary-epiglottic fold is a little puffy at its lower and posterior part. 
The left ventricular band is very slightly swollen anteriorly so that 
the outer border of the .left vocal cord in this situation is just 
covered; the right ary-epiglottic fold is normal, and the inter- 
arytenoid fold toward the left side has lost its sharp definition; an 
enlarged vessel is seen on the right ventricular band, which is other- 
wise healthy. The left vocal cord is of a pale pink color. At its 
posterior extremity there is a roundish growth about three milli- 
metres in diameter and two in height. On whispering, both the 
ab- and the ad- ductive action of the left vocal cord is seen to be 
feeble, but on loud phonation the latter movement shows no defect. 
The right vocal cord is healthy. In the subglottic region there is 
slight congestion, but no thickening is visible." 




Fig. 4. — Sketch made June 28, showing the larynx after complete removal of the 
growth. There is a very slight thickening near the posterior extremity of the 
left vocal cord. (For further explanations, see Fig. i, p. 104.) 



DR. MACKENZIE' S REPORT. 



129 



It will be seen, both from Dr. Wolfenden's very careful leport and 
from ray notes, that His Imperial Highness's throat was stiil some- 
what congested, and I thought it necessary to get rid of this con- 
dition before further active measures were employed. With this 
object sedative and astringent powders were blown into the wind- 
pipe, and after a few days the parts were brushed with a solution of 
perchloride of iron. His Imperial Highness came to my house 
nearly every day for treatment, and in the evening he was seen by 
Dr. Wolfenden. On June 25, the Prince had a rather sharp attack 
of catarrhal inflammation involving nearly the whole of the throat, 
causing swelling and tenderness of the uvula, and giving rise to 
slight difficulty in swallowing. 

My Fourth Operation. 

These symptoms, however, speedily subsided, and as nearly three 
weeks had passed since the previous operation, I thought it lime to 
make another attack on the growth. On June 28, in the presence 
of Drs. Wegner and Wolfenden, I succeeded in bringing away with 
the forceps what appeared to be all that was left of it. Dr. Wegner 
at once took possession of the substance which had been removed, 
and packed it up carefully with his own hands, declining even the 
assistance of my secretary. He then sealed the little packet, which 
was conveyed by one of the Royal messengers to Berlin, and handed 
to Prof. Virchow for examination. The following is a translation of 
that gentleman's report : 

Prof. Virchow's Report * on the Portion of Growth Removed from 
THE Larynx of H. I. H. the Crown Prince of Germany, by Dr. 
MoRELL Mackenzie, on June 28. 

" At midday this day, I received by special messenger from General-Arzt Dr. 
Wegner, a sealed flask containg the small portion of the pathological growth just 
removed from the larynx of H. I. and R. H. the Crown Prince. The object was 
in absolute alcohol in one piece, and though somewhat shrivelled was well pre- 
served. It had a flat base of longish oval form 5 millimetres long and 3 
millimetres broad, upon which was a small semi-spherical granular surface, about 
2 millimetres high. The latter surface had a gray color, with a faintly ruddy tint ; 
but the base was almost black. This was evidently from the action of some pre- 
paration of iron, for when moistened with hydrochloric acid the dark hue gave 
place to a faintly yellowish tint, which changed to an intense blue color on the addi- 
tion of a' little cyanide of potassium. The paler portions of the growth also 
showed this reaction m a higher degree. We must assume, therefore, that the 
iron preparation affected the whole surface, but that only the underlying portions 
preserved the blue-black tint, the superficial parts having become decolorized; 
further, that the flattish base represented the site of attachment of the portion in 
question, although its black color might at first give the idea that it had been 
superficial (in the larynx), and therefore more exposed to the action of external 
operations. 

* Brit. Med. Jotirn., vol. ii., 1887, p. 199. 



I30 CASE OF EMPEROR FREDERICK III. 

Further examination showed that the flattened base consisted of club-shaped^ 
rounded papillary outgrowths lying in juxtaposition ; moreover, that a whitish 
incision wound, hardly one millimetre wide, ran nearly across the middle of the 
base, following the long axis pretty closely, and almost wholly concealed by the 
surrounding papillary outgrowths. 

Microscopical examination showed still more decisively than on the previous 
occasion that the surface of the excised portion was almost wholly occupied by 
papillary outgrowths of various size. Only in the immediate neighborhood of the 
surface of excision was there found a small zone of perfectly smooth superficial 
tissue ; within the papillae the large and hard epithelial cells, in layers and flattened 
towards the outer parts, represented by far the chief portion of the new formation ; 
the connective-tissue framework was thin, soft, and vascular. No peculiar cell- 
formation was observed. 

The incised surface afforded an irregular, soft and slightly vascularized tissue. 
No deep layers of tissue, as after the first, and still fjiore the second, operation, had 
been removed. The section had been made very near the surface, so that only 
mucous membrane was removed. Thus only a little tissue, and that difficult to 
handle, was afforded for the purpose of an opinion on the structure of the under- 
lying parts. 

No alveolar structure, 01 deposition, or penetration of epithelial masses could 
anywhere be perceived in this tissue. It consisted of young connective tissue, 
which had increased not toward the deeper part, but toward the surface, and 
contained elements some of which were proliferating. Nowhere did this pro- 
liferation reach the character of an independent centre of formation. Thus this 
excised portion in a still higher degree than was the case with the portions ob- 
tained by the previous operations , has shown itself to be a hard, compj'essed, warty 
growth, that has started, from a moderately irritated and thicke^ted surface, and 
the examination of its base has not afforded the least support for the idea of a netv 
formation penetrating inward." * 

Rudolf Virchow. 
^^Pathological Iitstitute, Berlin. 
July I, 1887." 

It will be seen that this report, so far as it went, was as satisfac- 
tory as those which had preceded it. As only tissue belonging 
strictly to the growth had been removed this time, no opinion as to 
the underlying structures could, of course, be given. On both the 
former occasions, it will be remembered, Prof Virchow had dwelt 
with some emphasis on the fact that the forceps had brought away 
not only a complete section of the tumor, but portions of the struc- 
tures on which it was seated, which could thus be seen to present no 
suspicious appearance. I think it right to insist on this, because 
both Gerhardt and Bergmann speak as if only shreds from the sur- 
face of the tumor — the outer husk, as it were — -had been submitted 
to Prof. Virchow. The eminent pathologist's own words, in the 
report just quoted, as well as in the two preceding ones, leave no 
shadow of doubt on this point. It is impossible to get over his tes- 
timony, unless it be supposed that the creator of scientific pathology 

*It has already been pointed out (p. 119) that it is the ingro7vth of epitheHal tissue, here once 
more expressly stated to have been absent, which is the distinctive feature of cancer as comparable 
with other new growths. The italics in the above report are not in the origmal. 



DR. MACKENZIE'S REPORT. 131 

could not distinguish healthy from diseased tissue in a case where 
the merest beginner in microscopic work could do so without 
trouble. The notion is as preposterous as it would be to say that 
Gounod or Verdi could not distinguish a true note from a false one. 

Visit to the Throat Hospital. 

This seems the most appropriate place to mention a pleasant epi- 
sode belonging to this period, though it has nothing to do with the 
medical history of the case. On July 15 the Crown Prince paid a 
visit to the Hospital for Diseases of the Throat, Golden Square, an 
institution which, since I founded it in 1863, has relieved more than 
105,000 patients. I was unfortunately too ill to be present on the 
occasion, but I was informed by the members of the committee who 
had the honor of receiving the illustrious visitor that His Imperial 
Highness expressed himself greatly pleased with all he saw. He 
showed the greatest interest in the patients, to each of whom he 
spoke a few words of kindly encouragement. A little girl who had 
undergone the operation of tracheotomy was sitting up in bed nurs- 
ing a doll. On being asked by the Crown Prince, " Which is the 
patient, you or the doll ? " the little mite answered, " Sure I don't 
know which it is, my dear ! " which delighted His Imperial High- 
ness. There happened to be three German patients in the hospital 
at the time, and of them naturally the Crown Prince took special 
notice, asking each of them what part of Germany he belonged to, 
and a number of other questions. In the crowded out-patient room 
again he spoke to several of the sufferers awaiting their turns to be 
attended to. 

The Isle of Wight. 

Very little reaction followed the removal of the last portion of the 
growth, and the august patient proceeded to the Isle of Wight, 
where Norris Castle had been placed at his disposal by the Duke of 
Bedford. For reasons which will subsequently appear (see p. 248),. 
I think it well to mention here that it was the Crown Prince himself 
who chose the Isle of Wight as a place of residence. He was very 
fond of the island, and he liked Norris Castle, where he had stayed 
before, and which had the advantage of being close to Osborne. 
Dr. Wolfenden continued in attendance, and it was arranged that I 
should go down once a week. 

A New Symptom. 

His Imperial Highness much enjoyed his stay in the Isle of 
Wight, and although I thought the climate seemed to have a relax- 
ing effect, he said he felt well, and was not tired after taking exercise. 



132 CASE OF EMPEROR FREDERICK III. 

On the day of the great naval review (July 23) the Crown Prince talked 
a good deal, and was very hoarse for a day or two afterward. On 
July 21 Dr. Wolfenden first noticed a slight swelling on the posterior 
surface of the arytenoid cartilages ; this observation I confirmed at my 
next visit. The thickening was in the form of a yellowish ridge; it 
projected to the extent of about one miUimetre, and extended across 
from the outer border of one cartilage to the corresponding part of 
the other. 

The appearance of this new feature in the case caused me consider- 
able anxiety, for I could not help fearing that it indicated inflamma- 
tion of the perichondrium, if not disease of the cartilages themselves. 
I therefore warned the Crown Princess and other exalted personages 
that the possibility of the occurrence of serious perichondritis at some 
future date must be taken into account. 

Galvano- Cautery as it should be used. 

Toward the end of July there was some appearance of recurrence 
at the seat of the growth which I had removed. It did not project 
sufficiently for the blades of the forceps to catch it ; I therefore de- 
termined to destroy it with electric cautery. This I did in a very 
careful manner, using an instrument specially constructed for the 
purpose by my assistant, Dr. Robert C. Myles, now of New Ycfrk. 
The electrode, the tip of which was bent at a right angle so as to 
reach under an overhanging ledge, was guarded by two ivory plates 
fastened on with silk thread covered with hardened gum-arabic, a 
substance which has been found to be an excellent non-conductor 
of heat. In this way only the tiny point remained free to touch the 
part to which it was applied. It was thus impossible to burn any 
part of the larynx except the spot which it was desired to reach, nor 
could the heat of the incandescent point be felt by the parts which 
it did not actually touch, as is often the case with the ordinary in- 
struments. Every provision against all conceivable accidents having 
thus been made, on August 2 I applied the cautery, using the ut- 
most gentleness in manipulation, and merely touching the site of the 
growth with the point. The Crown Prince felt hardly any incon- 
venience from the application, which was not followed by any ap- 
preciable reaction. The next day a small, flat eschar was visible at 
the spot which the cautery had touched, but Dr. Wolfenden in- 
formed me that there was no appearance of inflammation round it. 
Six days later I again applied the galvano-cautery, with the same 
precautions as before, in the presence of Drs. Wegner and R. C. 
Myles. 



DR. MACKENZIE' S REPORT. 133 

Scotland. 

On August 9, the Crown Prince started for Scotland, accompanied 
by Dr. Wegner, Dr. Landgraf, and Mr. M..rk Hovell, Surgeon to 
the Hospital for Diseases of the Throat, who had succeeded Dr. 
Norris Wolfenden as Resident Physician, domestic circumstances 
preventing the latter gentleman from continuing his services. The 
Crown Prince went on to Braemar, attended by Mr. Hovell ; whilst 
Drs. Wegner and Landgraf remained at Edinburgh, so as to be 
within reach in case of emergency. As there has, I believe, been a 
good deal of comment on this arrangement, I may here take the 
opportunity of stating that I had nothing whatever to do with it. 
My advice on the subject was not asked, and was therefore not 
given. The Crown Prince simply acquainted me from time to time 
with the arrangements which had been made. Whilst informing me 
that Wegner and Landgraf were to stay at Edinburgh, he told me 
that it had been settled that they should both pay him a visit at 
Braemar. 

On August II, Mr. Hovell wrote to me that a small slough, 
caused by the cautery, had come away, and two days later he in- 
formed me that the slight wound had healed. The growth thus de- 
stroyed never returned, 

.During His Imperial Highness's stay at Braemar a marked im- 
provement took place in the condition of the larynx. The lining 
membrane was much less congested, and his voice became strong 
and almost natural in tone. The Queen expressed to Mr. Hovell 
the pleasure she felt at hearing the Crown Prince speak once more 
in his own voice. 1 visited the Prince at Braemar on August 20, 
and found that the ridge on the posterior surface of the arytenoid 
cartilages had almost disappeared. I saw him again in London on 
August 31, when I noticed that the left cord moved more freely than 
before, though its action was still imperfect. His general health at 
this time was excellent. 

Plajis for Autumn. 

As His Imperial Highness had expressed a wish to go for some 
weeks to Toblach, in the Tyrol, of which place he had very 
pleasant reminiscences from a previous visit, and as I saw no objec- 
tion to his gratifying his wish in that respect, it was arranged that 
he should go to the Austrian Alps. I advised him, however, if he 
found the climate of the Tyrol at all cold to go further south. He 
determined not to pass through Berlin, greatly as he should have 
liked to see the aged Emperor. As the Crown Prince himself 
pointed out, however, if he went to Berlin he would have had to 
receive visits from a very large number of people and this would 



134 CASE OF EMPEROR FREDERICK III. 

have involved an enormous amount of talking, which he feared 
would hurt his throat. In this decision there can be no doubt that 
from a medical point of view His Imperial Highness was entirely- 
right ; a visit to Berlin under such circumstances would have been 
only too likely to do him much harm. The Prince also told me 
that Dr. Wegner's place would be taken for a time by Dr. 
Schrader, as the health of the former was not quite satisfactory, 
and His Imperial Highness said that he himself was now so well 
that he did not require any other doctor with him but Mr. Hovell, 
with whom he expressed himself highly satisfied. For this reason, 
he added, Dr. Landgraf would be relieved of further attendance on 
reaching Germany. 

Gerhardfs Assistant as a Larytigoscopist. 

With the disappearance of the young Stabsarzt from the scene I 
feel it necessary to say a few words on a subject I would have 
gladly refrained from touching on. The importance attached by 
my German critics, however, to what I may call Dr. Landgraf's 
evidence, leaves me no alternative but to speak quite plainly on 
this matter. After Dr. Landgraf's first examination, the Crown 
Prince complained to me of his roughness and want of skill, and 
on many subsequent occasions His Imperial Highness assured me 
that after the young German surgeon had used the laryngoscope, 
his throat felt sore and tired for several hours. The Crown Prince, 
whose consideration for the feelings of others was of the most 
chivalrous description, bore with the infliction as long as he pos- 
sibly could ; but after a time he asked me if I could not give 
Landgraf a hint to be more gentle and to take less time in making 
his examinations. I ventured, however, to represent to His Im- 
perial Highness that this would place me in a very invidious 
position, and that it would be said in Germany that I did not wish 
Landgraf to get a proi)er view of the larynx. I had two or three 
times the opportunity of seeing him examine the Crown Prince's 
throat, and his performance was almost as painful for me to witness 
as it was for the august patient to undergo. Just before his 
departure for Scotland His Imperial Highness again complained to 
me about Landgraf's clumsiness, and I felt it necessary to tell Dr. 
Wegner that if the young surgeon did not mitigate his style of 
examination, I was sure that the Crown Prince would send to 
Berlin for some less inexperienced laryngoscopist to replace him. 
Dr. Wegner begged me to use my influence with His Imperial High- 
ness to prevent a step being taken which would have a most injurious 
effect on Landgraf's career, while he promised to warn the young 
surgeon to be more careful in future. 



DR. MACKENZIE'S REPORT. 135 

I confess after seeing how little familiar Dr. Landgraf was with 
the laryngoscope I did not attach any importance whatever to his 
observations. And it would seem as if Landgraf was regarded at 
Berlin very much as he was by me, for though this gentleman every 
few days sent from the Isle of Wight and elsewhere most alarming 
reports to the Prussian capital, no more notice was taken of them 
than if they had been drawn up by a person who had never used 
the laryngoscope. I shall refer to this matter again in dealing with 
Dr. Landgraf's separate report. 

When the Crown Prince was staying in the Isle of Wight, Land- 
graf, who had then been some weeks in attendance, seems to have 
suddenly become distinctly aware that the left vocal cord did not 
move quite as it should do. This startling discovery he forthwith 
communicated to some of His Imperial Highness's suite, and it 
finally came to the ears of the Crown Prince, who was rather 
alarmed about the matter. When, however, I explained to him 
that the condition which Landgraf had just noticed for the first 
time * had existed from the date of my first visit to Berlin, he was 
perfectly satisfied ! Again Landgraf appears to have mistaken the 
ridge outside the larynx behind the arytenoid cartilages which I 
have described (p. 132) for a swelling on the posterior wall, that is to 
say, inside the larynx below the level of these cartilages. On this, 
as I afterward learned, he founded most alarming reports of can- 
cerous infiltration spreading round the orifice of the windpipe, 
which, as we now see, have been duly deposited in the archives of 
the Prussian Kingdom! 

I found that Dr. Wolfenden entirely agreed with me as to Dr. 
Landgraf's want of laryngoscopic skill. To him also the Crown 
Prince repeatedly complained of the German surgeon's examina- 
tions, and my colleague expressed to me his surprise that if it was 
thought necessary to send any one from Berlin, a more competent 
observer was not chosen. 

When, in November, a report based upon Landgraf's observa- 
tions was drawn up at Berlin, I requested Dr. Wolfenden to give me 
his views on the subject in writing. The following is his statement: 

" I never considered Landgraf a person to be treated seriously. 

* At the time I was under the impression that Landgraf had recognized the imperfect action of 
the left vocal cord for the first time, and I am still unable to account for his extraordinary excite- 
ment on any other ground. I was very much surprised, therefore, on looking over Dr Land- 
graf's report, to find that this condition is mentioned m his first letter to Berlin. The only expla- 
nation 1 am able to offer now is that, although he denies it. Dr Landgraf mu^t have received 
some useful "hints from Prof Gerhardt " It would appear, therefore, that Landgraf inhisearlier 
reports embodied the hints, whilst on .i certain date he actually saw what he had previously 
described from the " Informationen " of Prof Gerhardt {Op cH.\ which the professor evidently 
gave to his assistant before he heard that the young surgeon had been appointed to "control" me. 
After that time Gerhardt says. " I ceased to have any correspondence with Dr. Landgraf on this 
subject " (Op cit., p. 15.) As all the instructions were evidently already given, no further corres- 
pondence was required. 



136 CASE OF EMPEROR FREDERICK III. 

Whatever he may be as a surgeon, and of this I have no knowl- 
edge, he is certainly nothing of a laryngoscopist. His laryngo- 
scopic examinations of the Crown Prince were prolonged, unskil- 
ful, and exceedingly tiresome, so much so that the Crown Prince 
made a complaint after the second examination at Norwood, and 
asked me whether he should not speak to Landgraf and request him 
to desist from examining his throat daily. The Crown Prince stated 
also that Dr. Landgraf 's examinations were painful to him, and his 
manner objectionable. I had not the slightest confidence in the 
accuracy of Dr. Landgraf 's observations, as he constantly imagined 
he saw things which were not present, and at the same time over- 
looked the most obvious phenomena. Notwithstanding this, I 
never stood in his way, and whenever he expressed a desire to 
examine the Crown Prince's throat, I always permitted him to do 
so before I myself applied any medicament." 

It is with the greatest reluctance I have had to deal thus frankly 
with Dr. Landgraf, but so much lias been made by ray opponents 
of his testimony, that I am compelled in self-defense to show exactly 
what value should be attached to it. 

Possibilities of the Case. 

Shortly before their Imperial Highnesses left England, I thought 
it my duty to lay before the Crown Princess my views as to the 
prospects of the Prince. I told the Princess frankly that although 
at that time the affection did not seem to me to be of a malignant 
nature, it might nevertheless turn out to be so. I fully explained to 
her what in my opinion the four possible developments of the case 
might be: i. The tumor having been destroyed might not grow 
again, the affection being thus practically cured. 2. The tumor 
might sprout up again, and require to be removed or destroyed 
perhaps more than once. 3. A condition known as "multiple papil- 
loma " might result, which was dangerous if not properly treated, 
but not necessarily fatal. 4. The disease might be cancerous already, 
or cancer might develop later on. I impressed upon Her Imperial 
Highness that although at that moment everything looked most 
promising, the possibility of an eventual unfavorable development 
must not be ignored. That I laid my views before the Princess in 
the frankest and most unreserved way I have documentary evi- 
dence to prove, and I am quite ready to place this evidence before 
the President of the College of Physicians and the German Ambas- 
sador acting together. With the Crown Prince himself I of course 
could not discuss the situation with the same freedom ; but whilst 
encouraging him as to his condition, I was careful not to say any- 
thing of a misleading character. 



CHAPTER XVII. 



TOBLACH — VENICE — BAVENO. 



The Case enters on a New Phase, 

The Crown Prince left London on September 3, and traveled by 
Frankfort and Munich to Toblach, which he reached on the 7th. 

In Mr. Hovell's note-book, under the date of September 9, I find 
the following note : " During the journey the Crown Prince's throat 
has certainly been more relaxed ; on the 6th I noticed that the 
cushion of the epiglottis was congested and slightly swollen ; on the 
7th, on arriving at Toblach, this feature had almost entirely disap- 




Fig. 5. — Sketch showing Mr. Hovell's observations on September 9. 

peared, but the right ary-epiglottic fold was shghtly inflamed, just at 
the point where it joins the arytenoid cartilage, and the cartilage of 
Wrisberg was more prominent on this side ; the inter-arytenoid fold 
was also slightly puffy, though of normal color. On the 8th, the 
congestion of the right side had entirely disappeared, but there was 
a small hyperasmic spot just below the inter-arytenoid fold. There 
was no swelling whatever, however, in the situation. I observed 
slight thickening at the hinder part of the left vocal cord, rather 
farther back than the site of the growth which Sir Morell had 
destroyed. There was increased hoarseness, with some congestion 
of the larynx, which, however, soon subsided. On the 14th, an 
oblong swelling, about 5 miUimetres in length and 3 in width, was 
noticed half an inch below the middle of the left cord and parallel 



138 CASE OF EMPEROR FREDERICK III. 

with its margin. On the i8th, the tumefaction at the posterior part 
of the cord had disappeared, but the new subglottic tumor was 
still visible." 

On the 2oth, when I arrived at Toblach, the sweUing was nearly- 
round, and measured more than half a centimetre in diameter, but 
projected very slightly from the side of the larynx. The Crown 
Prince looked well, and Dr. Schrader gave me a very satisfactory 
report as to his general health. When out walking, however, he 
seemed to get tired sooner than the rest of the party. Two days 
after my arrival he caught cold, and on the following day he was 
languid, had no appetite, whilst his temperature was ioi° F., and 
the left ary-epiglottic fold suddenly became oedematous ; but this 
condition, together with the feverish symptoms, disappeared in 
twenty-four hours. Although the oedema was apparently due to 
inflammation from taking cold, the possibility of its being caused 
by limited perichondritis was discussed at the time. It should be 
noted that the acute oedematous swelling just referred to seemed to 
be altogether independent of the little tumor beneath the edge of 
the vocal cord, which became gradually smaller but did not entirely 
disappear. 

A Deceptive Lull. 

It had already been arranged that the Crown Prince should 
spend the winter in Italy, and San Remo was now decided on as 
the most suitable place for him. As the weather was becoming 
rather cold at Toblach, I advised His Imperial Highness to spend a 
week or two previously at Venice, of which he was very fond. He 
accordingly went there on September 28, and stayed till October 6, 
the condition of his larynx meanwhile steadily improving. On the 
7th he went to Baveno, where Mr. Henfrey had placed his beauti- 
ful villa at his disposal. Here I found the Crown Prince's throat 
in a very satisfactory state, except that the left cord did not move 
quite freely, and its posterior extremity was on a somewhat higher 
level than the corresponding portion of the right. I judged that 
some perichondria! inflammation had taken place about the anterior 
spur of the left arytenoid cartilage, and that this had pushed the 
vocal cord a little upward in that situation. There was no redness, 
however, at that spot, and I therefore hoped that the morbid pro- 
cess had been arrested. In the larynx itself there was at this time 
nothing beyond slight general congestion and the remains of the 
subglottic swelling which had been discovered on September 14. 

Hopes and Fears. 
I then took leave of His Imperial Highness, not expecting to see 
him again for many months. That I did not, however, even at that 



DR. MACKENZIE' S REPORT. 139 

time take an entirely optimistic view of the situation is clearly shown 
in the following passages of a letter which I wrote to Prof. Oertel 
of Munich on October 21 in reply to one which I received from him 
soon after my return to London : 

" With regard to your inquiries about the Crown Prince, I am happy to tell 
you that when 1 saw him at Baveno he was going on very well. There has 
never been anything at all characteristic of malignant disease as far as (the naked 
eye) appearance goes, so that my treatment has throughout been based on the 
observations of your great pathologist. Valuable, however, as Prof. Virchow's 
investigations have been, they of course only furnish negative evidence, and 1 
shall not feel quite safe from anxiety until six months have elapsed since the 
application of electro-cautery. I need scarcely assure those who know me that 
I have never been in the least unwilling to meet my German confreres, and 
should any unfavorable symptoms unfortunately develop, I should be the first to 
ask for the co-operation of one of your countrymen. 

" With regard to the publication of bulletins, I quite agree with you that fre- 
quent official communications are desirable, as they often allay anxiety, and 
prevent the spread of false news. In the case of a private person, however, 
this question always rests with the patient, and it does not seem right that 
because the sufferer is of the highest rank his own feelings in the matter should 
be disregarded. 

" Yours truly, 

" MoRELL Mackenzie." 

Clouds Gathering. 

Things went on well till about the middle of October, when Mr. 
Hovell's reports began to be less favorable. On the 17th, the larynx 
became acutely congested, and ten days later the subglottic swelling 
was seen to be increasing in size, and the whole of the left side of 
the larynx was somewhat enlarged. On October 28, the surface of 
the tumor became slightly ulcerated, and the vocal cord above it 
was slightly swollen along its free edge. In spite of this, the illus- 
trious patient's voice was quite clear, and in the opinion of the 
Crown Princess perfectly natural. A mournful interest attaches to 
this remark of Her Imperial Highness, for this was the last time she 
was ever to hear the true sound of that beloved voice. The next 
day the Crown Prince became hoarse again, and on October 30 a 
new swelhng was noticed beneath the right vocal cord, whilst the 
one on the other side was seen to be throwing out off-shoots. 
Nevertheless, except the renewed hoarseness, there was little to indi- 
cate, either to the illustrious sufferer himself or to others, that a 
change for the worse had occurred. 

On November 3, the Crown Prince proceeded to San Remo, 
where a suitable residence, the Villa Zirio, had been prepared for 
him. On that day Mr. Hovell perceived that the subglottic tumor 
had grown considerably, being then rather more than one centi- 
metre in diameter, and raised to the extent of about four millimetres. 



I40 CASE OF EMPEROR FREDERICK III. 

The extension of the growth since it was first observed had always 
been in an upward direction. On the morning of the 4th some 
oedema was seen at the base of the left arytenoid cartilage ; this dis- 
appeared in the evening, but was again present on the following 
morning. As the symptoms now presented a decidedly ominous 
appearance, an urgent message was sent to me, on receipt of which 
I at once started for San Remo, which I reached on the evening of 
the 5th. 



CHAPTER XVIII. 



SAN REMO — THE WORST FEARS CONFIRMED. 



A New Growth Appears. 

On the morning of Nov. 6 I examined the Crown Prince's throat, 
which I found in exactly the condition described in the reports. 
The mucous membrane over the left arytenoid cartilage was moder- 
ately cedematous, and of a bright pink color. The new growth was 
bright red in color, rather more prominent in the centre than else- 
where, and ulcerated on the surface. Its appearance was altogether 
unlike that of the one which I had destroyed, and the other swell- 




Fig. 6. — Sketch made Nov. 6, showing a large new growth half an inch below ihe 
left vocal cord, and a smaller one below the right cord. 

ings which had from time to time shown themselves in the larynx; 
it had in fact a distinctly n-'alignant look. Without rising from my 
chair I informed His Imperial Highness that a very unfavorable 
change had taken place in his throat. He said, " Is it cancer ? " to 
which I replied, " I am sorry to say, sir, it looks very much like it, 
but it is impossible to be certain." I felt that evasive answers, which 
for the patient's own sake medical men are often compelled to give 
under similar circumstances, would in the present instance have been 
out of place. The Crown Prince received the communication with 
perfect calmness. After a moment of silence he grasped my hand 
and said, with that smile of peculiar sweetness, which so well ex- 
pressed the mingled gentleness and strength of his character, " I 



142 CASE OF EMPEROR FREDERICK III. 

have lately been fearing something of this sort. I thank you, Sir 
Morell, for being so frank with me." In all my long experience I 
have never seen a man bear himself under similar circumstances 
with such unaffected heroism. He showed not the least sign of de- 
pression, but spent the day in his ordinary occupations ; and at din- 
ner time that evening he was cheerful without apparent effort, and 
chatted freely in his usual manner. A day or two afterward, in re- 
ply to a question as to his general health, the Crown Prince said he 
had never felt better in his life, adding, with a smile, " Under the 
circumstances, I really must apologize for feeling so well ! " To ap 
preciate the extraordinary fortitude displayed by this magnanimous 
man, it must be remembered that what he had heard was something 
much worse than a mere sentence of death. He believed at that 
moment that he was doomed only too surely to a lingering agony 
worse than death. There is nothing more terrible than the struggle 
of a powerful constitution with the slow but relentless advance of 
malignant disease, when the life is as it were eaten out of a man bit 
by bit, and each day's sufferings are made worse by the anticipation 
of those that are to come. This was the prospect which the Crown 
Prince " looked forward to without fear, placing his trust in God," 
to use his own words ; it was one which would have struck dismay 
into the heart of many a brave man who has never felt fear on the 
battlefield. 

With the view of having the diagnosis confirmed by the evidence 
of the microscope, it would have been more satisfactory to have 
removed a portion of the growth with forceps, and to have sub- 
mitted it to Prof. Virchow. Such a procedure, however, was 
clearly out of the question whilst the larynx was in so " angry " a 
condition as it then was ; any additional irritation would have cer- 
tainly made matters worse. It was fortunate for me that I did not 
attempt anything of the kind, for two days later, acute oedema of 
the upper opening of the larynx on both sides set in spontaneously ; 
this condition would inevitably have been attributed to my operation 
had I ventured to perform one. 

A Coiisultation Called. 

In such a serious state of affairs it was of course desirable to have 
further advice, not that much could be hoped for from medical 
skill in such a case, but that no opportunity of possible help, how- 
ever slight, should be neglected. 

The question was : Where should it be sought for ? It was 
before everything essential to have the assistance of men who would 
bring absolutely unbiased judgments to the case. At Berlin, to 
which my thoughts naturally first turned, there was no one (setting 



DR. MACKENZIE'S REPORT. 145 

aside Gerhardt and Tobold, who had already strongly committed 
themselves to an opinion on the matter) but Prof. Bernhardt 
Frankel and Dr. Hermann Krause. Prof. Lewin, who had 
formerly been a distinguished laryngologist, i ad long since given up 
the specialty, which has for some reason or other never flourished 
very vigorously in the Prussian capital. The want of official 
recognition by the University, from which it suffered till com- 
paratively recent times, has probably been the chief cause of its 
feeble vitality in that city. At Vienna, on the other hand, which 
was the cradle of this department of medical science, the tradition 
has been kept up, and laryngology has always been well represented 
in the professorial body. 

The Counsellors Chosen. 

I now carefully weighed the respective merits of the three 
leading throat-specialists in the Imperial City. If I had been 
selecting an operator, I probably should have chosen Prof. Stork ; 
and if I had been dealing with a disease of such obscurity that the 
the widest experience was required, I should have invited Prof. 
Schnitzler, but at that moment the diagnosis appeared only too 
clear. In the end I selected Prof, vo 1 Schrotter, mainly in the 
hope that his extensive knowledge of respiratory affections would 
enable him to make some practical suggestions in connection with 
treatment. Of the two available laryngologists at Berlin I chose 
Dr. Krause, with whose knowledge and ability I had been greatly 
struck at the International Medical Congress held at Copenhagen 
in 1884. On that occasion I was president of the Section of 
Laryngology, a dignity which was conferred on me as a special 
honor, contrary to the almost invariable custom at these gatherings 
where the presidential chairs are filled by local men of " Hght and 
leading." In that position I had an excellent opportunity of 
forming a judgment as to the abilities and attainments of the prin- 
cipal European and American specialists. Amongst them all no 
one made his mark more decisively than Krause, who at once took 
his place as one of the leading laryngologists in Germany. The 
distinction which he earned at Copenhagen has been more than 
sustained by his subsequent work, of which I shall speak more in: 
detail further on. (See page 258). 

The Consultatio7i. 

At my request, therefore, Prof, von Schrotter and Dr. Krause- 
were summoned to San Remo. On November 9, a preliminary 
meeting took place in my room at the Hotel Mediterranee, Prof, von 
Schrotter, Dr. Schrader, Dr. Krause, Mr. Hovell, and myself being; 



144 CASE OF EMPEROR FREDERICK III. 

present. I gave an account of the case from the time I first had 
seen the Crown Prince in May till the day I took leave of His 
Imperial Highness at Baveno in October. Mr. Hovell then 
related the subsequent progress of the case from that time up to the 
date of our meeting. I then described the appearance of the new 
growth as I had first seen it on November 6, and concluded by 
saying, " This growth looks like cancer." Prof, von Schrotter 
thereupon said that, after my very clear statement, he had no hesi- 
tation in pronouncing the disease to be cancer ; he was so sure of 
it that he felt there was no need for him to see the patient. Whilst 
thanking the professor for this flattering testimony to my descriptive 
powers, I ventured to point out that it was hardly worth his while 
to have come all the way from Vienna to give it, and I hinted that 
it would scarcely be treating the illustrious patient with proper con- 
sideration to offer him a second-hand diagnosis. Prof, von Schrotter 
then consented to go with us to the Villa Zirio, where the Crown 
Prince's throat was duly examined. 

Upon returning to the hotel to continue the consultation, Prof, 
von Schrotter wished to dictate a report tx cathedra, hvX as there 
was some divergence of opinion between him, Dr. Krause and 
myself, it was agreed that each should give his opinion separately in 
writing. Schrotter affirmed that the disease was cancer, and recom- 
mended excision of the entire larynx. Dr. Krause remarked that 
it appeared to him that it was highly probable that the disease was 
a "malignant neoplasm," but as the view of the interior of the 
larynx was almost completely shut out by oedema, he would be glad 
to know whether iodide of potassium had been administered with 
the object of clearing up the diagnosis by the exclusion of the 
presence of any chronic contagious disease.* In my protocol I 
stated that in my opinion the disease was cancer, pointing out, 
however, that in the absence of microscopic evidence such a diag- 
nosis could not be made with certainty. I therefore recommended 
that as soon as the oedema had disappeared, a small piece of the 
new growth should be removed through the mouth and submitted 
to Prof. Virchow, on whose report as to its nature any future course 
of action should be based. 



Conference with Prince William. 

Whilst we were discussing the case from every side, we learned 
that Dr. Moritz Schmidt had come to San Remo with instructions 
from the Emperor to draw up a report on the case of the Crown 
Prince. We accordingly invited him to be present at the remainder 

* On the principle expressed in the old axiom, Naiuram morbi ostendit curatio 



DR. MACKENZIE' S REPORT. 145 

of the consultation. In the evening Prince WiUiam, who had by 
this time arrived, desired that all the physicians and surgeons in 
attendance should be present at a conference in his room in the 
hotel. We had only been there a few minutes when the Crown 
Prince sent for me. I am not therefore in a position to say what 
passed at this meeting, but I understand that the chief subject of 
discussion was who should perform tracheotomy if that operation 
became necessary. 



Dr. Schmidt's Opinion. 

The next day a further consultation took place at the Villa Zirio, 
in which Dr. Schmidt, by permission of His Imperial Highness, 
took part. On this occasion Prof, von Schrotter, without explaining 
why he did so, receded from his former position and advised against 
any external operation being undertaken, except tracheotomy, when 
the necessity for it should arise. Dr. Krause and myself adhered 
to the views we had already expressed. Dr. Schmidt put forward 
very strongly the idea that the disease might be the result of an 
infection which had remained in the system for many years, and 
urged that large doses of iodide of potassium should be given. 
Prof, von Schrotter here interrupted Dr. Schmidt rather warmly, 
saying, that such a notion was " an old wife's tale " {altes Weiber- 
.geschwdtz). Dr. Krause, whilst allowing that the balance of evi- 
dence was altogether against Dr. Schmidt's view, said there could 
be no harm in trying the effect of the drug which had been 
proposed. To this Schrotter and I assented, though neither of us 
had the least belief in the theory on which the suggestion was based. 
I may mention here that before Prof, von Schrotter left San Remo, 
I again spoke to him on this subject, and he told me that he had 
only agreed to iodide of potassium being given, because no external 
operation was going to be done. Had such a measure been con- 
templated he assured me that he would not have sanctioned the 
administration of that remedy. 

At this consultation it was agreed that a statement, setting forth 
the advantages and disadvantages of excision of the larynx, both 
partial and complete, should be drawn up and submitted to the 
Crown Prince, to whom the decision as to the course to be adopted 
should be left. I thought it better that the statement should be 
drawn up by a physician absolutely free from, bias in the matter than 
by one who like myself had throughout the case shown himself op- 
posed to severe measures, and at my request Prof, von Schrotter 
was good enough to undertake the preparation of this document. 
The results of these operations will be found set forth in Section III, 



146 CASE OF EMPEROR FREDERICK III. 

Tables II and III in this work. A short bulletin was next drawn 
up, which it was understood was exclusively for the information of 
the Emperor. In this we expressed the belief that the disease from 
which the Crown Prince was suffering was cancer. In signing this 
document both Mr. Hovell and I considered that we did so subject 
to the reservation indicated in my special protocol of November 9. 
At this meeting it was also agreed that we should formally make the 
Crown Prince acquainted with our views at a personal interview. I 
requested Prof, von Schrotter to be our spokesman on the occasion, 
because where a communication of such importance had to be made, 
and a definite meaning had to be conveyed in carefully chosen 
words, it seemed best that His Imperial Highness should be 
addressed in his native language. I was afraid that if I myself 
undertook this delicate task it might afterward be said that I had not 
made the full gravity of his position clear to the illustrious patient, 
and had in this way influenced his decision as to future treatment. 

The Diagnosis Commiaiicaied to the Crotvii Prince. 

Prof, von Schrotter discharged his vinpleasant duty with great tact 
and judgment in the presence of the Crown Princess and all the 
doctors. His Imperial Highness remained standing while the pro- 
fessor was speaking, and received the terrible commimication with- 
out any emotion. He was the calmest person in the room. Though 
Schrotter did not use the word " cancer," he made it perfectly clear 
to the Crown Prince that that was what we believed him to be suffer- 
ing from. I am absolutely sure that His Imperial Highness was 
under no misapprehension on the subject. 

The Crown Prince's Decisio?t. 

We then withdrew, after placing the statement as to the opera- 
tions on the larynx in the hands of the Crown Prince. In the 
course of a few minutes we received a communication from His 
Imperial Highness, written with a perfectly steady hand, stating that 
he declined to have his larynx excised, but would submit to trache- 
otomy should it become necessary. It was then agreed that this 
operation should, when the time came, be intrusted to Prof, von 
Bergmann, unless difficulty of breathing came on suddenly, when it 
would have to be done by some one on the spot. Bergmann was 
selected, not because tracheotomy in a grown-up person suffering 
from intrinsic disease of the larynx is an operation of any particular 
difficulty, but because, as he had already been in attendance on the 
illustrious patient, it seemed right that he should do whatever had to 
be done in the way of surgery. 



DR. MACKENZIE' S REPORT. 147 

PublicatioJt of our Secret Report. 

Before separating, we received the most solemn injunctions not to 
divulge our opinions as to the nature of the case or the practical 
results of our deliberations. The necessity of absolute secrecy on 
these points was impressed on us both by Dr. Schrader, and by 
Count Radolinski. We were given to understand that the German 
public was to be gradually prepared by a series of cautiously worded 
bulletins which should make the real state of the case generally 
known without shocking the feelings of the Crown Prince. This 
humane intention was, however, frustrated by ihe immediate publi- 
cation of our private bulletin to the Emperor in the Official Gazette 
( Reichs-Anzeiger ), Not only those of the doctors who were still at 
San Remo, but the officials of the Crown Prince's court, were 
amazed on learning this event by telegraph. Whether the occur- 
rence was simply due to a mistake, or whether there was some state 
reason for publishing the bulletin, I do not profess to know, but it 
seemed no less strange than unfortunate that so important a state- 
ment, made under the seal of the strictest secrecy, should have been 
at once published with the apparent sanction of the supreme 
authority, and should thus have been, so to speak, thrust without 
any disguise or palliation under the eyes of the person chiefly 
concerned. 

I left San Remo on November 18, and at my last interview I made 
a careful examination of the Crown Prince's throat. The following 
are my notes : " The growth beneath the left vocal cord is smaller 
and less prominent, and the ulcer on its surface appears also slightly 
diminished. The oedema on the right side of the larynx has almost 
disappeared. There is scarcely any movement of the left vocal 
cord, which is congested and swollen. The right vocal cord is red, 
and is slightly thickened at its posterior extremity. The small growth 
below the right vocal cord remains unchanged." 

From this date till the middle of December I received a series of 
reports signed by Dr. Krause and Mr. Hovell; the latter gentleman 
also sent me private letters containing references to the case, for 
which of course he is solely responsible. 

Reports frottt San Remo. — November 18. — " Congestion of the mucous mem- 
brane. It is easy to see the capitiilmn Santorini at the apex of the left arytenoid 
cartilage; swelling less, right side free." 

November 20. — "The ulcerating surface beneath the left vocal cord is less 
prominent, and the ulcer situated at the posterior part of the left ventricular band 
is smaller in size. There is slight movement of the left arytenoid cartilage. In 
other respects the appearance is the same. The voice is still rough, but clearer." 

Mr. Hovell further reported to me that Dr. Bramann, chief, 
assistant to Prof, von Bergmann, had been sent to San Remo by 



148 CASE OF EMPEROR FREDERICK III. 

desire of the Emperor in order to be in readiness to perform trache- 
otomy, should it be necessary to do it suddenly. 

November 28. — "There is now no ulceration to be seen. The part of the 
growth which first appeared is smaller and smoother. There is now a cicatrix on 
the portion of the ventricular band formerly occupied by an ulcer. The conges- 
tion of the larynx and the swelhng of the left side are less. The right vocal cord 
is less swollen but still congested, especially on the processus ■vocalis, in which 
portion it is a little more swollen." 

November 29. — " During the last week or ten days the enlargement of the 
submaxillary glands has materially diminished, especially on the left side, and 
these glands are now hardly to be felt." 

On December i, Mr. Hovell wrote to me as follows: 

"AH the local symptoms ameliorated. Dr. Bramann, who was very anxious to 
make a laryngoscopic examination, was allowed by His Imperial Highness to do 
so. He has evidently not had any practice in the use of the instrument, and 
certainly did not see much, if he saw anything at all." 

The joint reports of Krause and Hovell then continue : 

December 4. — " During the last week the swelling of the left side of the larynx 
has diminished to such a degree that the left ventricular band is seen at times to 
vibrate. The yellowish prominent ridge on the margin of the left ventricular 
band has now again diminished, although it was rather more prominent a few 
days ago. The congestion of the larynx has, on the whole, been less." 

December II. — " A few days ago two small nodules appeared on the edge of 
the left ventricular band, near its anterior part. They have increased in size, and 
have united to form one growth, which has been increasing rapidly, and now 
occupies the posterior three-fourths of the left ventricular band." 

Bramajin as a Laryngoscopist. 

On this subject Mr. Hovell wrote to me as follows : " Three days 
ago Bramann again tried to use the laryngoscope, and caused the 
Crown Prince a good deal of annoyance. He introduced the 
mirror into the throat very fairly, but had very great difficulty in 
focussing the light. The luminous disc was seen to be bobbing 
about everywhere except on the laryngeal nrirror. At last, how- 
ever, he did get it on, but then he seemed to forget that the mirror 
was in the patient's throat, and kept it there exactly as he might 
have done on 2, papier mdcAe mode\. I am sure, however, he did 
not see much, as, after he had got the hght, he slanted the mirror 
in such a way that it only reflected the back of the tongue. I had 
taken the precaution beforehand to tell Schrader what really was 
present, as I knew he would ' coach ' Bramann on the subject. The 
latter, however, thought that he would make some discoveries for 
himself, and I understood from Krause, that he (Bramann) said that 
the tumor extended above the thyroid cartilage ! ! After Bramann's 
attempted investigation 1 told the Crown Prince that I thought it 
was not only useless for him to have his throat examined by that 
surgeon, but that it might give rise to erroneous statements being 



DR. MACKENZIE' S REPORT. 149 

circulated respecting his condition. I reminded His Imperial High- 
ness that Dr. Landgraf had sent most ridiculous statements to 
Berlin, and I said Bramann might do the same. I finally observed 
to the Crown Prince, ' I can see that Dr. Bramann is not accus- 
tomed to use the laryngoscope.' ' Yes,' said His Imperial High- 
ness, ' you can see it, and I ca.n feel it ! ' " 

The following is the report of Dr. Krause and Mr. Hovell on 
December 13: "The growth has increased during the last two 
days, especially on its inner surface, which now forms an irregular 
projection toward the mesial line. This morning the left ven- 
tricular band is sHghtly swollen at its anterior part. The general 
congestion of the larynx has increased." 

About this time I pointed out in England that the treatment 
which I had carried out had been unanimously agreed upon by all 
the physicians and surgeons in attendance on His Imperial High- 
ness, after Virchow had published his report, and that it was not 
merely based on my own diagnosis. The circumstances which 
called forth this definition of my position, was an annotation in the 
British Medical Journal of December 10, 1887. The following is 
an extract from a letter which I pubhshed in the same journal on 
December 17 : 

"When I arrived in Berlin, I gave it as my opinion that the appearances were 
negative ; that is, that they were compatible with the growth being either 
malignant or benign. I therefore suggested that a portion should be removed 
per vias naturales, for microscopical examination, and the treatment which I 
finally recommended was based on the clinical aspects of the case, plus the 
results of Prof . Virchow^ s microscopical examinatien. 

" I may add that, as after Dr. Virchow had made his report, the proposed line 
of treatment was unanimously agreed to by those present at the consultation, all 
my colleagues were equally responsible for the views entertained at that period. 
There is no reason, therefore, why I should be singled out as having formed a 
' clinical opinion,' or indeed as having arrived at any opinion different from that 
of my German colleagues. The only difference which existed was the different 
opinion held by my confreres before my removal of a portion of the growth, and 
[that which they entertained after] * the reception of Dr. Virchow's report 
thereon. I am, etc., 

"MoRELL Mackenzie." 

"December I2." 

* This sentence, though in the original, was accidentally omitted by the printer. 



CHAPTER XIX. 



SAN REMO — SUSPENSE. 



/ am Recalled to San Remo. 

On December 12, a further rapid development of the vegetations 
on the left ventricular band having taken place in the course of a 
few hours, it was feared that more alarming manifestations might 
follow, and I was again hurriedly summoned to Italy. I arrived at 
San Remo on Dec. 15, and was pleased to find a marked improve- 
ment in the condition of the Crown Prince as compared with what 
it had been a month before. The swelling of the submaxillary 
glands had subsided, and no trace remained of the inflamed and 
ulcerating tumor below the left vocal cord except a smooth, red scar. 
Covering the posterior half of the left ventricular band, however, 
were some small, white vegetations, which appeared here and there 
to be undergoing ulcerations. Mr. Hovell informed me that these 
vegetations had been much larger on the 13th, when they seemed 
to be hourly increasing in size ; they had, however, begun to slough 
on the evening of the 14th. The day after my arrival I found that 
a considerable further diminution had taken place, both in their size 
and number. On that day I had the honor of accompanying the 
Imperial family to Ospedaletti, and I noticed with some surprise 
that the Crown Prince was the most vigorous walker in the party. 
His Imperial Highness complained to me of the conduct of Dr. 
Moritz Schmidt, who, as he told me, had thought fit to give a lec- 
ture on his case at Frankfort after his return from San Remo, in 
which he had openly stated that the disease from which the illus- 
trious patient was suffering was of " contagious " origin. The Crown 
Prince expressed the greatest annoyance at Dr. Schmidt's indiscre- 
tion, and begged me to contradict the statement, for which I may 
here say there was not the shadow of a foundation. 

A Favorable Turn. 

As the laryngeal affection seemed to be in a somewhat active 
state, I determined to remain in the south for a little time, and on 
December 17 I went for a trip to Algiers, returning to San Remo on 



DR. MACKENZIE' S REPORT. 151 

the evening of the 27th. I found that the vegetations on the left 
ventricular band were now very slight, and limited to its posterior 
part; there was, however, a little pufifiness at the upper part of the 
band where it joined the ary-epiglottic fold, and the remains of the 
subglottic growth projected rather more toward the glottis. The 
larynx was rather congested, and could be felt from the outside of 
the neck to be somewhat swollen on the left side. On the whole, 
however, the condition of the august patient was much better than 
it had been at the time of my first visit to San Remo. 

After my return home I continued to receive reports from Dr. 
Krause and Mr. Hovell as to the progress of the case from time to 
time. On January 2, in addition to the swelling below the right 
vocal cord, some tumefaction was noticed at the front part of the 
corresponding ventricular band, whereby the anterior extremity of 
the underlying cord was hidden from view. The congestion of the 
larynx and trachea had increased, and there was a copious secretion 
of mucus. On January 12, all that remained of the growth on the 
left ventricular band was a little thick-being which was fast dimin- 
ishing. Since the date of the previous report there had been rather 
more swelling of the left side of the larynx, together with greater 
congestion, and a more profuse discharge of mucus. All these 
local symptoms, however, were said to be subsiding, and the illus, 
trious patient's general health was quite satisfactory. 

A Change for the Worse. 

Almost immediately after this one of those sudden exacerbations 
of the symptoms occurred which formed so remarkable a feature of 
the case. I give below the detailed reports which I received from 
Dr. Krause and Mr. Hovell, as they supply an accurate picture of 
the clinical incidents from day to day, and show in a very striking 
manner the suddenness of the change which took place between 
January 13 and 14: 

January 13, 1888. — " The thickening on the left ventricular band, which marks 
the seat of the last growth, has almost disappeared. The swelling of both ven- 
tricular bands is decidedly less, and that beneath the right vocal cord has dis- 
appeared, except at its anterior part, where it still remains to a slight extent. 
The congestion of the larynx and trachea is less. There is no glandular enlarge- 
ment. " 

January 14, 8.30 A. M. — "This morning a whitish-gray prominence has been 
observed beneath the left vocal cord, narrowing the lumen of the air-passage and 
producing slight stridor. Temperature, 99-8'' Fahrenheit. Pulse, 94." 

January 14, 9 p. m. — "During the day there has been a hoarse cough, but 
unaccompanied with much expectoration. Breath fetid. Temperature, lOi'S*^ 
Fahrenheit. Pulse, 96." 

January 15, 10 A. M. — "This morning the whitish prominence is seen to have 
increased in size since last night, and to now extend two-thirds across the lumen 



152 CASE OF EMPEROR FREDERICK III. 

of the air-passage. The glands on the right side, beneath the jaw, are enlarged. 
Temperature, IOO-8'' Fahrenheit. Pulse, 78." 

January 15, 9 p. M. — " This evening the whitish-gray substance above referred 
to is seen to be composed of some soft substance, which moves to and fro with 
forcible inspiration and expiration. Respiration less interfered with than in the 
morning. Glandular enlargement somewhat increased. Cough less frequent, 
but more expectoration. Temperature, 102" Fahrenheit." 

January 16, 8.30 A. M. — " Has passed a quiet night. Respiration free. Mem- 
brane still adhering to left side, but projecting less into lumen of air-passage. 
Less foetor. Temperature, 99 '8° Fahrenheit." 

January 16, 9 P.M. — " Condition much the same. Temperature, IOO° Fahrenheit." 

January 17, 9 p. M. — " About five o'clock this morning, after a violent fit of 
coughing, a slough, about three and a half centimetres in length and one centi- 
metre wide, came out. Temperature, 99" Fahrenheit." 

January 18, 9 P. M. — "The expectoration, since the slough came away, has 
been tinged with blood. Temperature, 99"4'' Fahrenheit." 

The slough was sent to Prof. Virchow for examination, and the 
following is thaj; distinguished pathologist's report thereon : 

Report of the Examination of the Slough from the Larynx of His Im- 
perial Highness the Crown Prince of Germany. By Prof. Rudolf 

Virchow.* 

"On the morning of January 26, 1888, Dr. Wegner brought me a sealed box, 
with a letter dated January 23, from Dr. Schrader from San Remo. It was ac- 
companied by a report dated January 1 7, from Dr. Krause, respecting a large 
piece of tissue which had been expectorated on the same day from the larynx of 
His Imperial Highness the Crown Prince. 

" The portion sent was the whole of the matter expectorated, with the excep- 
tion of six small particles removed by Dr. Krause for examination [by Dr. 
Heryng of Warsaw, then staying at San Remo]t in the fresh state. The piece 
of tissue was in a sealed bottle containing absolute alcohol. In addition to the 
large portion referred to, there were also two other separate and somewhat harder 
pieces — a larger and a smaller. The former, according to Dr. Krause, was origin- 
ally a part of the principal mass. The examination offered great difficulties, the na- 
ture of which could not have been anticipated either from the form or the appear- 
ance of the pieces submitted for investigation. The large mass greatly resembled 
certain portions of imperfectly masticated pieces of meat, which are sometimes 
rejected in vomiting after being swallowed. This view seemed to derive support 
from the presence here and there of small, yellow and brownish particles of 
fine cellular vegetable structure, and from the existence in the innermost portion 
of the large piece (expectorated) of an abundance of elastic fibres. 

" In consideration, however, of the very precise information conveyed by Dr. 
Krause to the effect that the substance had been observed before its separation 
(from the larynx) extending from beneath the left ventricular band from the middle 
to the anterior angle, and also below the glottis, and even round below the an- 
terior part of the right vocal cord, there could be no doubt, on further examina- 
tion, that we had to deal with a large slough spontaneously separated from the 
inner surface of the larynx, and not with a purely exudative (fibrinous) mass. In 
the substance, which, according to the report of Dr. Krause, when first expecto- 
rated, measured three and a half centimetres in width, whilst at the thinner end 
it was half a centimetre in width (its thickness being four millimetres), and at the 

*The above is taken from the Lancet, February 18, 1888. 

t The sentence between brackets was not contained in the original report. 



DR. MACKENZIE'S REPORT. 153 

thicker end one centimetre wide, a small, smooth, semi-circular spot in its long 
diameter could be seen. All the rest of the surface was occupied by long and 
very closely arranged fibres. Although there was no epithelium on the smooth 
spots and no glands beneath it, it cannot be doubted that this was the free sur- 
face of the mucous membrane. For beneath it could be seen microscopically a 
thin layer of almost homogeneous connective tissue and a great mass of elastic 
fibres. Beneath this there was deeper down a very thick layer, consisting 
especially of tubules with granular amorphous contents. From this thick layer 
originated the long fibres observed with the naked eye. It was not once possi- 
ble to recognize in these tubular layers and transverse stripes, but they seemed 
to contain only amorphous matter, in which, on more minute examination, nu- 
merous micrococci were found. Here and there numerous, but very small, 
clear blown bodies or crystal-like deposits were observed. Nevertheless, I 
have no doubt that these tubular layers and fibres are primitive muscular fasci- 
culi, which through a necrotic process have been destroyed. The slough must 
therefore be regarded as a necrotic and decomposed part of the larynx, which in 
parts has been separated from the surface to a depth of four millimetres. The 
very rich muscular structure could only be attributed to the thyro-arytenoid 
muscle. 

" I could not determine what kind of morbid process had caused the gangrene, 
nor what kind of process had produced the demarcation and exfoliation of the 
substance. Neither pus-corpuscles nor granulation-cells could be distinguished, 
and, in fact, in most places there was nothing of a heterogeneous nature to be 
discovered. Only in the larger (of the two smaller pieces), which had been 
cut off the main mass by Dr. Krause from a somewhat hard spot, and which 
had the form of a flat wart on section with the naked eye, a central whiter and an 
external and opaque rather thick covering could be distinguished. In every mi- 
croscopic section so-called nests {Zwiebeln) of epidermoidal cells, for the most 
part of a homogeneous character, were seen. As a rule, these nest-cells were in 
the most external layer or in that lying immediately beneath it. The external 
layer had also most likely consisted of an epidermoidal formation, though these 
cells could only be here and there partially distinguished. I could not find epi- 
dermoidal cells in the deep parts, and distinctly isolated alveoli were nowhere to 
be discovered, in spite of assiduous researches. 

" These examinations will be continued, and if any further result is obtained I 
will send a report instantly. 

" Rudolf Virchow, 
Director of the Pathological Institute, 
" Jamcary 2g, l888.. Berlin.'''' 

Prof. Virchow subsequently sent several private letters, in which, 
however, he did not add anything to the original report as given 
above, but he stated that he had not been able to find cartilage in 
any portion of the slough. The notes of Dr. Krause and Mr. 
Hovell continue as follows : 

January 22. — "During the last few days the swelling beneath the right vo- 
cal cord has reappeared, but the respiration is not interfered with. There has 
been but little expectoration during the last twenty-four hours, and no blood is 
now mixed with the mucus expelled. The glands are still enlarged ; the temper- 
ature has been normal since last note." 

January 25. — "Since the last feverish attack some general swelling has re- 
mained beneath the vocal cords, and this has caused the voice to be less clear 
than it was previously. The upper part of the larynx has been only slightly 



154 CASE OF EMPEROR FREDERICK III. 

congested for some time past, and a very slight thickening now only remains to 
show the seat of the last growth." 

The Cause of the Trouble. 

This attack was due to the local irritation set up by the presence 
of the slough which was practically a foreign body in the larynx, 
and to the systemic disturbance associated with the efforts of the 
part to get rid of the offending substance. After the extrusion of 
the fragment of dead tissue the feverish symptoms subsided, and the 
condition of the larynx became comparatively comfortable. It was 
obvious, however, that the local disease was entering on a phase of 
fresh activity, and this naturally made the watchful observers in 
attendance on the Crown Prince somewhat anxious as to the future. 
It was therefore decided on January 27, to summon me again. 



CHAPTER XX. 



SAN REMO — THE TRACHEOTOMY. 



Further Developments. 

On arriving at San Remo on the afternoon of January 29, 1 found 
the Crown Prince looking fairly well, but much thinner. I made a 
laryngoscopic examination in the presence of Dr. Krause and Mr. 
Hovell. The growth at the posterior extremity of the left ven- 
tricular band had disappeared ; but lower down I saw a red, sHghtly 
raised scar, extending parallel with but below the left vocal cord 
along its whole length. Toward the middle of the cord there was 
a small patch about three milhmetres in length, and one millimetre 
in depth, which did not appear to be completely healed. Beneath 
the right vocal cord there was a swelling occupying the middle and 
anterior portion of the subglottic region. 

After the consultation, Dr. Schrader represented to me that Dr. 
Bramann was anxious to examine the illustrious patient for himself, 
and asked me to invite him to take part in our consultation the next 
day. Whilst pointing out that Dr. Bramann was at San Remo, not 
as one of the attending physicians, but solely for the purpose of 
performing tracheotomy, should the necessity for that operation 
arise too suddenly to allow Prof, von Bergmann to be sent for, I 
said that I was perfectly willing that he should see the Crown Prince 
if His Imperial Highness did not object. Later in the day, having 
obtained the consent of the august patient, I called on Dr. Bramann 
and invited him to be present at the consultation on the following 
morning. He accordingly came, and I watched him make his ex- 
amination. It was obvious that he had had Httle or no experience 
in the use of the laryngoscope ; but he tried to supplement his im- 
perfect observations with the mirror by percussion of the larynx — a 
mode of examination which has been abandoned by modern physi- 
cians as utterly useless. 

Inexperienced Laryngoscopists. 

I may here take the opportunity of saying, that as nothing is more 
irritating, even to a healthy throat, than attempts at laryngoscopic 



156 CASE OF EMPEROR FREDERICK III. 

examination made by a 'prentice hand, I consider that I should 
have been amply justified in declining to allow the Crown Prince to be 
made the subject of such rudimentary efforts. Dr. Landgraf s exam- 
inations, as has been said, were sufficiently trying to the illustrious 
patient, but the throat at that time was comparatively well. When 
Dr. Bramann used the laryngoscope on the Crown Prince, matters 
were very different, and it was essential that every cause of irritation 
to the swollen and ulcerated parts should be as far as possible 
avoided. It can easily be imagined that the coughing and retching 
produced by awkward handling of the mirror would be in the highest 
degree mischievous to the diseased larynx. This is so true that I 
myself have been, although quite unjustly, blamed for making too 
frequent examinations. Yet it is now actually made a ground of 
serious complaint against me, that I tried to prevent the future 
Emperor of Germany from being made a subject for the experiments 
of beginners ! It was one of the most distressing features in this 
case that the patient's very importance, from a political point of 
view, tended to make regard for his personal feelings an altogether 
secondary consideration with many people. Had he been a private 
gentleman, I should never have allowed him to be subjected to 
examinations which could be of no earthly use, and which there is 
too much reason to fear did positive harm. I may add, that no 
private patient I have ever met with would have submitted to them. 
As according to the reports of Dr. Krause and Mr. Hovell there 
had not been much change in the local symptoms during the pre- 
vious two or three days, I took the opportunity of going to Barce- 
lona to see a patient from whom I had received several urgent 
messages. On my return to San Remo on February 7, I found that 
the affection had made rapid progress in the interval. The swelling 
of the left side of the larynx had increased, and there was also 
marked tumefaction below the right vocal cord. There was now 
very slight but distinct noise in inspiration, especially when the 
august patient was talking. In quiet respiration, however, when he 
was silent, there was no audible sound. On going upstairs to his 
room in the evening I noticed that he went quite as quickly as 
formerly; that is to say, quicker than most people, but he was 
slightly out of breath when he reached the top landing, and I advised 
him to walk up more slowly in future. I should mention that the 
rooms on the ground floor were very lofty, so that the ascent up the 
stairs was considerable. On inquiry, I found that the Prince was 
still sleeping with only one pillow under his head, and I recom- 
mended him to use one or two more pillows, This will show how 
very slight the difficulty of breathing was. The illustrious patient 
complained of headache, which Dr. Schrader attributed to want of 



DR. MACKENZIE'S REPORT. 157 

oxygen — commencing asphyxia in fact ! I prescribed a nerve seda- 
tive, which quickly reheved the neuralgia. 

Urgent Symptotns. 

On the morning of the 8th we found that His Imperial Highness 
had not had a very good night ; the breathing was about the same. 
At the evening visit the illustrious patient said he felt very well. I 
sent word to Ur. Bramann that I should be glad if he would take 
part in the consultation the next morning. On the 9th we found 
that the Crown Prince's rest had been much broken by fits of cough- 
ing, but he said he felt very well in spite of having had a bad night. 
On making a laryngoscopic examination, I found that the whole of the 
left side of the larynx down to the level of the left vocal cord below 
the epiglottis was very much swollen and inflamed. During deep 
inspiration the subglottic region on the right side was seen to be 
very red and swollen ; in fact the mucous membrane in this situa- 
tion formed a distinct broad-based tumor about five-eighths of an 
inch in diameter, which considerably diminished the lumen of the 
lower part of the larynx. After we left, the illustrious patient had 
breakfast, and ordered the carriage for a drive at ten o'clock. He 
stepped briskly into his carriage, and was much disappointed when 
he heard that a mistake had been made in bringing it round, and 
that I had left directions that it would be better for him not to 
go out. 

Tracheotomy decided on. 

After seeing the Crown Prince we proceeded to discuss the situa- 
tion. The disease had burst into renewed activity so suddenly, and 
the swelling had encroached on the breath-way to so great an extent 
in the course of a single night, that I thought there would be the 
gravest risk in postponing the establishment of an artificial passage 
even for twenty-four hours. I therefore urged that tracheotomy 
should be performed at once. In this I was supported by Dr. 
Krause and Mr. Hovell, who of course were in a position to esti- 
mate the pressing nature of the case. Dr. Bramann, who from 
inexperience in this particular department could not realize the con- 
dition, was strongly in favor of postponing the operation till Prof, 
von Bergmann could arrive. Dr. Schrader, who, even before I left 
for Spain, was anxious that tracheotomy should be done, and who 
on my return from that country pressed for the performance of the 
operation without delay, now most anxiously pleaded that we should 
wait till Bergmann arrived. He said, " It would make a very bad 
impression at Berlin if the operation were done by any one else than 
Bergmann," and seemed to fear that he would get into disgrace if 



158 CASE OF EMPEROR FREDERICK III. 

the arrival of that surgeon was not awaited. So strong a sense, 
however, had I of the danger of delay that I felt compelled to say 
plainly that if the operation were postponed I should decline all 
further responsibility, and that those who opposed its performance 
would be answerable for the Crown Prince's life. On this Schrader 
and Bramann gave way, begging, however, that ice-compresses 
should be applied to the neck for three or four hours in order to see 
if the inflammation showed any tendency to subside. I consented 
to this, and immediately after our consultation I paid a visit to the 
Crown Prince, and ordered the ice-compresses, but told him that I 
was afraid that tracheotomy would have to be performed in a few 
hours. He said, " I feel perfectly well, if it were not for the slight 
difficulty in breathing ; but if you say the operation must be done, I 
have no objection." Soon after twelve o'clock, having noticed that 
the difficulty of breathing was increasing, I informed Dr. Bramann 
that I thought it would not be safe to put off the operation much 
longer, and advised him to visit the illustrious patient again. After 
he had done so he proceeded to make arrangements for the opera- 
tion, which was fixed for 3 p. m. 

Shortly before that hour we all assembled at the Villa Zirio, and 
there was some debate as to whether chloroform should be adminis- 
tered. I am myself opposed to the use of this anaesthetic in such 
cases, as I think it increases the danger of the operation, and the 
pain of the incision can be almost entirely deadened by freezing the 
skin. Occasionally, in the case of a very nervous patient, I have 
found it necessary to administer laughing-gas, followed by ether, 
but I never use chloroform. Dr. Schrader, however, explained to 
me that as Bramann had never performed tracheotomy without 
chloroform, it would try his nerve very severely to dispense with it 
in such a case as the present. I therefore urged the Crown Prince 
to consent to be anaesthetized, and, after discussing the matter at 
some length, His Imperial Highness said, " If you approve of it, 
Sir Morell, I will take chloroform." 

The Operation. 

When everything was ready, the Crown Prince passed through an 
adjoining room into his ordinary sitting-room, where it was arranged 
that the operation should be performed. The bed was placed op- 
posite one of the windows, so that there was an excellent light. 
Bramann proceeded to give chloroform, but as soon as the Crown 
Prince had become unconscious, the administration was continued 
by Dr. Krause, whilst I kept my finger on the pulse at the left 
wrist. Shortly after Dr. Bramann had made his first incision, I no- 
ticed that the pulse had become very weak, and that the face was 



DR. MACKENZIE' S REPORT. 159 

blanched ; in fact there were evident signs of cardiac weakness. On 
raising the eyeHd the pupil was seen to be widely dilated. The chlo- 
roform was suspended for a minute or two, when the pulse became 
fairly good again, and the operation was proceeded with. After 
this incident Dr. Bramann seemed to become a little flurried, 
though not to such an extent as to prevent him from operating with 
skill. In opening the windpipe, however, I noticed that he made 
his incision a little to the right instead of in the middle line. The 
deviation appeared to me so slight at the time that I attached no 
importance to it. After opening the trachea, instead of at once 
plunging in the canula as is usually done by English surgeons, 
Bramann held aside the two sides of the wound for a minute or 
two until the bleeding had ceased, and then inserted a very large 
and long tube. I will frankly own that the delay in introducing 
the canula seemed to me an improvement on the ordinary plan of 
plunging the tube into the windpipe as soon as it is opened — a 
proceeding which usually sets up severe spasm and cough. 

When the operation was completed I congratulated Dr. Bramann 
on his success. I have already said that in a case like that of the 
Crown Prince tracheotomy is not, as a rule, a matter of any diffi- 
culty, but considering that the young surgeon was operating on his 
future sovereign, and that he was not unnaturally somewhat un- 
nerved by the catastrophe so nearly caused by the chloroform, I 
think he did his work very well. On leaving the room, I said to 
Mr. Hovell, " Did you notice that the trachea was opened a little 
to the right of the middle line," and that gentleman replied, " I did ; 
but I should say considerably , rather than a liiiley*' On coming to 
himself the illustrious patient shook hands warmly with Dr. Bra- 
mann, myself, and, I believe, the other doctors. 

As the case here enters on a phase of the highest importance, 
and as the various episodes must be related in detail in order to 
make the general situation intelligible, I propose to continue the 
narrative in the form of a daily record. The facts were all duly re- 
corded in my note-book at the time, and the following pages are 
little more than a reproduction of my notes, with a running com- 
mentary to make their purport clear to ordinary readers. From the 

* I should have been glad to have avoided this subject, had it been possible, but unfortunately 
soon after the operation took place, the fact that the opening was made to the right of the median 
line was mentioned in the British Medical Joii-rna.1, and is referred to at considerable length by 
the writers of the pamphlet entitled " Die Krankheit der Kaiser Friedrich des Dritten." When I 
first saw the statement in the British Medical jfottrnal, both I and my colleague, Mr. Mark Ho- 
vell, were much surprised, and greatly regretted that the facts had got into print. I am permitted 
by Mr. Hovell to state that, on sifting the matter, he ascertained that the account got inserted in 
the following way : Mr Mark Hovell wrote a description of the operation to his lamented father, 
not intending it to be made use of in the press. Unfortunately Mr, Hovell, Sr., described the de- 
tails to a gentleman connected with the British Medical Journal, but I am quite sure that he had 
no idea that the facts described by him would be published. 



i6o 



CASE OF EMPEROR FREDERICK III. 



day of operation till the Emperor's death I was never away from 
him for more than a few hours. 

Dr. Bramami' s Canula. 

February 9. — I was very anxious when I saw the kind of canula 
that Dr. Bramann had inserted into the trachea ; it was very large, 
and also the longest tube I had ever seen inserted, immediately af- 
ter the performance of tracheotomy. It is true that in certain cases 
where disease creeps down the trachea longer tubes have to be 
inserted from time to time, but I have never seen a case in which so 
long a tube was used from the first. Besides its unusual size and 
length, its upper orifice was considerably larger than the lower, so 




Fig. 7. — Bramann's canula; from a tracing of the original instrument. On 
comparing it with Fig. 8, which is the drawing of an ordinary full-sized canula, 
the extraordinary size and curve of Bramann's tube will be at once evident. 

that it had somewhat the shape of a funnel. Any practical surgeon 
looking at the annexed drawing (Fig. 7), which was actually traced 
from the tube used, will see that the instrument was exceptional in 
every respect, and widely differing from the ordinary full-sized can- 
ula (Fig. 8), was eminently calculated to cause irritation of the tra- 



DR. MACKENZIE' S REPORT. i6i 

chea; and it will be seen how the lower and back part of the 
instrument caused a wound in the posterior wall of the trachea by 
pressing on that point. 

February lo. — The Crown Prince had a disturbed night, and 
there was a small amount of mucus with cough about every two 
hours, sometimes oftener. The mucus was thin and pink, as is gen- 
erally the case directly after tracheotomy. This results from a little 
blood oozing from the wound trickling down into the windpipe, 
from which it is ultimately coughed up. Considering that the oper- 
ation had only been performed the day before, I thought the illus- 
trious patient's appetite tolerably good. 




Fig. 8. — An ordinary full -sized canula, from a tracing. 

There were now six medical attendants to look after the Crown 
Prince, and for some time after the operation each of us took his 
turn at the Prince's bedside. I came on duty at six o'clock every 
evening and remained until ten ; and though I was not now in 
charge of the case I paid frequent visits to His Imperial Highness 
during the day. 

My Report on the Case. 

February lo. — This evening the illustrious patient expressed a 
wish that I should issue another official report on his case. I at 
once set about drawing it up, and two days later forwarded it to the 
principal German and English medical papers. It will be seen that 
it is d. precis of much that has been stated in these pages, but it may 
perhaps be considered to have a certain historic value. From my 



1 62 CASE OF EMPEROR FREDERICK III. 




Fig. 9. — Diagram, showing Bramann's canula (half size) in situ, a, the gullet ; 
b, the larynx with the trachea below. The canula is seen cutting into the back 
wall of the trachea as occurred in life. 

own point of view, it is of some importance, inasmuch as some 
months before the fatal issue of the case, it clearly defined my po- 
sition in the spring and summer of 1887. 

The Case of His Imperial Highness the Crown Prince of Germany.* By 
Sir Morell Mackenzie. 

" His Imperial Highness the Crown Prince of Germany having expressed his 
wish that I should now place on record my opinion of his case, the opportunity 
is afforded of correcting some of the statements which from time to time have 
been inaccurately attributed to me. 

The general idea is that I am of opinion that the disease from which his Im- 
perial Highness is suffering is not cancer; t the view, on the other hand, which 
I have consistently maintained, is that there never has been any proof of the ex- 
istence of cancer. To enter more into detail : When I arrived in Berlin last May 
I stated to my colleagues that, in my opinion, the appearances seen in the throat 
were of a negative character — that is to say, that the disease might be either be- 
nign or malignant, and that its nature could only be determined by microscopical 
examination. A portion of the diseased tissue having been taken away by me 
from the throat of his Imperial Highness, it was submitted to Prof. Virchow, 
who could not detect in it anything of a malignant nature. Repeated examina- 
tions by Prof. Virchow of other portions removed by me yielded similar results. 

In the month of July, whilst His Imperial Highness was staying in the Isle of 
Wight, I pointed out to more than one of his august relatives that the danger 

* This report is taken from the Lancet, February i8, 1888. 

t In this statement the words "cancer," " cancerous, " and " mahgnant," are used synonym- 
ously. 



DR. MACKENZIE'S REPORT. 163 

that I most dreaded was the occurrence of perichondritis at a future date, and 
three months later this fear was proved to be well grounded. At the end of Oc- 
tober and early part of November entirely fresh symptoms appeared, and at that 
time the local disease presented an appearance which was consistent with the di- 
agnosis of cancer. It was then impossible to obtain any fresh microscopical evi- 
dence in the matter, and I considered it safer accordingly to treat the case as one 
of a malignant nature. At the same time, however, I drew up and submitted to 
my colleagues a protocol, in which I stated that although the disease at that mo- 
ment looked like cancer, I could not agree that the malady was proved to be ma- 
lignant until a further microscopical examination had been made. The document 
in which I set forth my views was forwarded to Berlin to be placed in the State 
Archives. Although the unfavorable symptoms then present were explicable 
on the ground of the existence of cancer, yet it was clear to the majority of the 
physicians at that time in attendance that perichondritis had supervened. 

In the middle of December, however, the unfavorable signs had passed away, 
and there were no longer any clinical symptoms of cancer. Microscopical evi- 
dence on the subject was, however, still wanting. This was furnished at the end 
of January, when a slough was expectorated from the very spot which had pre- 
sented such a highly suspicious appearance in November. This slough was most 
carefully and repeatedly examined by Prof. Virchow, and the result (which is now 
published) again shows that cancer could not be detected. 

To recapitulate. In my opinion, the clinical symptoms have always been entirely 
compatible with non-malignant disease, and the microscopical signs have been in 
harmony with this view. I need only add that, although in nearly every case of 
laryngeal disease it is possible at the first inspection to form an accurate opinion 
as to the nature of the disease presenting itself, yet in a few rare instances the pro- 
gress of the complaint alone permits its character to be determined. Unfortu- 
nately, the case of His Imperial Highness is among the latter number, and at this 
moment medical science does not permit me to affirm that any other disease is 
present than chronic interstitial inflammation of the larynx combined with peri- 
chondritis. 

Sail Remo, February 12, 1888." 

At the date of that report there was still no conclusive evidence 
of cancer, but the microscopic proof, that had hitherto been want- 
ing, was only too soon to be supplied. This, however, will be told 
in its proper place. 

The Canula gives Trouble. 

February 11. — The Crown Prince, who had at first been pleased 
with the results of the operation, now began to show signs of disap- 
pointment that he had not derived more benefit from it. He had 
several very violent fits of coughing, especially whilst trying to drink. 
I explained to him that this was a common symptom immediately 
after tracheotomy, which I hoped would disappear in a day or two. 
There was now a large amount of slimy expectoration streaked with 
blood. Prof, von Bergmann arrived this morning, and immediately 
presented himself to the Crown Prince. The professor joined us in 
a general consultation in the evening. At this time the illustrious 
patient's temperature was 100° Fahrenheit and the pulse 94; that is 



i64 CASE OF EMPEROR FREDERICK HI. 

to say, there was slight fever, due, no doubt, to the tracheal inflam- 
mation set up by the canula. My German colleagues, however, 
would not allow that a temperature of loo^ Fahrenheit indicated 
fever. His Imperial Highness sat up for three hours. 

February 12. — The Crown Prince complained very much of irri- 
tation in the windpipe, and asked if a different tube could not be 
inserted. The fits of coughing were much more frequent and 
severe, and prolonged paroxysms occurred even when no food or 
drink had been taken. 

/ Explain my Views to Braviann. 

During the morning Dr. Bramann paid me a visit at my hotel, 
and showed me two other tubes, both curved, and more or less 
resembling the one already in use. I told him that 1 thought 
neither of these tubes would answer, and I pointed out to him that 
the large orifice of his canulas would be likely to crush the rings 
of the trachea with which it would come in contact, and in this 
way in course of time cause destructive action of a serious nature. 
Dr. Bramann said that the orifice of the tube was made large in 
order to facilitate the expulsion of the mucus. To this I replied 
that as regards coughing, the power of expulsion would be dimin- 
ished by having the tube much larger at one end than the other, 
as the draught would thereby be diminished. Finally, I said that I 
considered his instruments antiquated [urall), whereupon Dr. Bra- 
mann left the room, apparently much offended. When I subse- 
quently went to Berlin and visited the instrument makers' shops, I 
found that the tubes which I had supposed to be antiquated had 
been specially made for the august patient ; that the large curve, 
the big instrument, and the large orifice were all specially designed 
for the benefit of His Imperial Highness. Whilst I regretted 
very much having regarded Dr. Bramann's instruments as anti- 
quated, I could not help feeling that this was scarcely a case in 
which it was desirable to try an experiment with a new kind of 
canula, and it would have been better for Dr. Bramann, though he 
had, no doubt, acted with the best intentions, to have used a tube 
which experience had proved to be useful. 

Suggestions from the Outside World. 

At this time the immense interest taken in the case throughout 
the civilized world led to my receiving innumerable letters recom- 
mending all sorts of remedies. For weeks after the tracheotomy 
they continued to pour in from all parts of Europe, and also from 
America. A kind of compress of live worms in a muslin bag was, 
according to many of these good people, the sov'ran'st thing on 



DR. MACKENZIE' S REPORT. 165 

earth in such a case as that of the Crown Prince. A great variety 
of prepared foods, peptonized preparations, essence of beef, an4 
zyminized nutriments, were brought under my notice. Cocoa pure 
and cocoa modified, peptonized and converted into an "elect ex- 
tract," was enthusiastically recommended. Malt extracts under 
various names, and in combination with both meat and cocoa, were 
much vaunted, whilst my friends in Scotland gravely assured me 
that if Highland whisky and oatmeal did not actually effect a cure, 
they would at any rate prolong life to its utmost limit. Mineral 
waters of every kind and from every place were sent in large quan- 
tities, and medicines of every description constantly reached me. 
Medical practitioners in different parts of Europe were also good 
enough to advise particular remedies. From England calcined 
oyster-shells had the most convincing vouchers; and, if human 
testimony is to be accepted, this remedy must have cured several cases 
of undoubted cancer. From France carbolic acid was the remedy 
most strongly urged upon me, both as a local injection and as an 
internal remedy ; whilst Dr. Bergeon's treatment was pressed upon 
me by several French physicians of eminence, who assured me that 
they had known cases exactly like that of the Crown Prince which 
had been cured by this method. The remedy most persistently 
recommended to me, however, was the quack medicine of Count 
Mattel, whose nostrums many persons in a high position of life most 
earnestly begged me to try. Dr. Schrader received from Germany 
large quanties of similar advertisements, which he informed me he 
forwarded regularly to Berlin, in order that they might be placed in 
the State Archives of the Haus-Ministerium, I was besought to 
use massage by dozens of people, and enterprising professors of 
that art offered to come at once from London, Paris, and even St. 
Petersburg, to exercise their skill. 

Turkish baths were pressed on my attention by philanthropic pro- 
prietors as an infallible means of purifying the body of every species 
of germs. Miraculous waters were sent by devout Catholics ; even 
magic was recommended. A lady earnestly entreated me to set on 
a table at the foot of the Crown Prince's bed " an oil lamp in which 
some water and salt had been placed." This lamp was to be 
lighted when the illustrious patient was asleep, and a small talisman 
(which was obligingly forwarded to me) was to be placed on His 
Imperial Highness's breast-bone when he was asleep. I was 
assured that if this was done the Prince would immediately begin 
to speak in his sleep, and would not only explain the nature of his 
malady but indicate the means of curing it. The tahsman con- 
sisted of two circular pieces of linen stitched together round the 
edges ; on cutting it open the precious phylactery was found to be 



1 66 CASE OF EMPEROR FREDERICK 111. 

nothing more than a piece of common flannel ! On my mentioning 
this thaumaturgic suggestion to the Crown Prince he smiled and 
said, " It is very kind of the lady, but I prefer to do without it." I 
may here say that even strong-minded persons, who know that they 
are suffering from hopeless diseases, often surprise their physicians 
by seeking help from the most stupid quackery as a drowning m.an 
grasps at a straw. The absolute freedom of the Crown Prince from 
weakness or superstition of this kind was not the least remarkable 
of his many admirable qualities. 

/ a7n Prevented from Giving Relief. 

February 14. — Though my colleagues thought the discharge from 
the trachea " moderate," it was more abundant than I hked to see, 
and it was much streaked with blood. I was now convinced that 
the lower end of the canula was pressing on the back wall of the 
windpipe and giving rise to tracheitis, and I asked to be allowed to 
introduce a short rectangular tube. I pointed out that when the 
tracheotomy wound healed it would be difficult to use my tube, as 
owing to the very long curve of the German tube mine would probably 
not adapt itself to the track made by that instrument, and in this way if 
the insertion of the rectangular tube were delayed too long it would 
itself cause similar irritation in a different part of the windpipe. 
Prof, von Bergmann would not, however, agree to my proposition. 

February 15. — The Crown Prince had a bad night, coughing 
almost incessantly ; the discharge was more copious, and contained 
blood, matter and mucus, with here and there small black shreds of 
tissue undergoing decomposition. It appeared as if the violent 
coughing was beginning to break down the diseased mass within 
the larynx. I was now getting very anxious, not so much about 
the progress of the disease, as about the way in which the after- 
treatment of the operation was being mismanaged, and again 
begged to be allowed to insert a rectangular tube. 

My Experience in Similar Cases. 

It certainly appeared to me that neither Prof, von Bergmann nor 
Dr. Bramann, well-informed surgeons though they doubtless were 
in many matters, had had much experience in the sort of work they 
had now taken upon themselves to do. Dr. Schrader told me that 
Bramann had performed tracheotomy four hundred times, but all 
these operations were cases so utterly unlike the present one that it 
would be simply misleading to class them together. Bramann's 
previous tracheotomies had nearly all been performed on infants 



DR. MACKENZIE' S REPORT. 167 

and young children for acute obstruction of the larynx, as in 
diphtheria. The large majority of these cases die soon after the 
operation, many indeed under the knife ; whilst in those who sur- 
vive, the tube is dispensed with after a short time. The case is alto- 
gether different in an adult, whose larynx is blocked up by new 
growth, which has a tendency to spread in the direction of greatest 
irritation. Here the parts require the most careful handling, and it 
is of the utmost importance to avoid anything that may lead to the 
larynx being shaken by coughing. Though my own experience of 
tracheotomy had not been so extensive as that of Dr. Bramann, yet 
my experience of the particular kind of case with which we were now 
dealing was far larger than his. Up to the year 1880 I had per- 
formed tracheotomy seventy-three times, sixty-four of these opera- 
tions having been done on adults, and nine on children. In addi- 
tion to this personal experience I had also been present at many 
operations performed on my patients by eminent surgeons, and I had 
often assisted my colleagues at the Throat Hospital in their opera- 
tions. Since 1880 Mr. Hovell has performed most of my operations 
in private practice, and has also attended the patients for a week or 
two after the operation under my general superintendence. At the 
very lowest computation I have certainly been present at 120 opera- 
tons. In the bulk of these cases the patients were adults suffering 
from diseases of a chronic nature. Many of them were cured, and 
the rest nearly all survived for some months. Thus, with a much 
smaller total of operations than Dr. Bramann, I had had a far greater 
number in which careful after-treatment was required. Prof, von 
Bergmann does not, I believe, profess to have any large experience 
as regards the operation of tracheotomy in adults. 

The Crown Prince attended to business to-day and walked up and 
down his room for a considerable time, both in the morning and the 
afternoon. He complained, however, of a neuralgic headache. 

February 16. — The condition was still most unsatisfactory ; the 
bloody mucus was more abundant than ever. His Imperial High- 
ness scarcely slept at all, either day or night, being awakened every 
half hour by fits of coughing. In spite of this, he was gaining 
strength a little. 

On this day Dr. Krause called on me, and invited me on behalf 
of von Bergmann to look at some microscopic preparations of 
minute sloughs thrown out in the expectoration. Dr. Krause said 
that he himself had examined them, and was satisfied they were of 
a cancerous nature, owing to the very large number of nest-cells 
which they contained. I told Dr. Krause that I did not profess to 
be a microscopist, and that so much depended on the situation of 
the " nests," and their relation to other tissues, that I did not feel 



1 68 CASE OF EMPEROR FREDERICK III. 

myself competent to judge in the matter. In a case of such vast im- 
portance, I thought the decision ought to be left to a pathologist of 
the first rank. 

My Examinations Objected to. 

February 17. — The Crown Prince again had a disturbed night; 
the cough was very harassing, and the bloody secretion abundant. 
I made a laryngoscopic examination, and found that the laryngeal 
canal was more open, and on closing the tube His Imperial High- 
ness was able to sound his voice very fairly. He did not, however, at 
all like the tone of it. There was not a trace of blood in the larynx, 
which proved that the blood in the expectoration came from 
elsewhere. 

February 18. — Another very bad night. The headache, however, 
had yielded to the remedy which usually gave relief. I announced 
to my colleagues that I found the condition of the larynx, relatively 
speaking, very satisfactory. In the evening Prof, von Bergmann 
stated at our consultation that my laryngoscopic examination on the 
previous day had been the subject of serious consideration by him- 
self, Dr. Bramann, and Dr. Schrader, and these gentlemen had re- 
quested him to say that they considered my having made such an 
examination in their absence a breach of professional etiquette. I 
answered that I did not think examining the throat any more of an 
operation than feeling the pulse or looking at the tongue, both of 
which I presumed they occasionally did when they were on duty; and 
I added that I should not have the slightest objection to either of 
those gentlemen making a laryngoscopic examination, if he could 
do so without inconvenience to the Crown Prince. As the matter 
was not worth making a fuss about, however, I promised for the 
future to give each of my colleagues formal notice whenever I pro- 
posed to make a laryngoscopic examination. 

Bergmann suspects Cancer of the Lungs. 

Although the illustrious patient's temperature was never much 
above the normal standard, we frequently examined the lungs, and 
on this day (19th) Prof, von Bergmann, after carefully percussing 
the right side of the back over the lower ribs, said he feared there 
was a secondary development of cancer in the base of the right 
lung, and that this was the cause of the hemorrhage. The pro- 
fessor did not seem to be aware that the dulness on which this 
diagnosis was founded was caused by the liver which occupied its 
ordinary situation over which he had been percussing. I pointed 
out to him, moreover, that such a condition as he believed to exist 



DR. MACKENZIE' S REPORT. 169 

was most unlikely to occur under the circumstances without some 
accompanying pneumonia, of which there was no trace. In thus 
seeking another cause for the hemorrhage Prof, von Bergmann 
showed that he had abandoned his previous theory that the bloody 
discharge all came from the larynx. The position which I main- 
tained at this time was as follows: The tracheotomy tube had 
caused great irritation as shown by muco-purulent and bloody dis- 
charge, and by frequent and violent coughing. This coughing after 
a time caused ulceration and disintegration of the morbid formation 
in the larynx, and the blood which at first had come solely from the 
trachea, rasped and wounded by the ill-fitting tube, now came from 
both trachea and larynx. 

My Tube is Tried Too Late. 

February 20. — On this day Prof, von Bergmann permitted me to 
insert a right-angle tube. Unfortunately, however, owing to the 
shape of the wound which the other instrument had made, it could 
not .est in a horizontal position, but was considerably lower at the 
inner end where it passed into the trachea than at the outer orifice. 
(See Fig. 10.) Although there was no longer any pressure from the 
posterior wall, I was sure that my tube would irritate the front part 
of the windpipe. This is what actually occurred, as indeed I had 
predicted on the 14th of February would be the case, if I was pre- 
vented from inserting the tube for some days. 

February 21. — The Crown Prince was exceedingly comfortable 
in the morning. He had slept well during the night, but toward 
the afternoon the tube was already beginning to chafe the anterior 
wall, and in the evening I found it causing almost as much irritation 
as the one it had replaced. During the day the Crown Prince had 
rather a long conversation with the Prince of Wales, who had 
arrived the day previously. 



I70 CASE OF EMPEROR FREDERTCK III. 




Fig. 10. — Diagram showing Durham's tube introduced too late, and not able to 
adapt itself to the track of the long German canula. Later on, this tube was 
worn (see Fig. i6) with comfort. It can be seen that the front part of the 
lower end of the canula is very near the anterior wall of the trachea, and that 
by the least coughing it would be sure to rub against the delicate lining of 
that tube. 

In the evening the Crown Prince also had an interview with the 
Grand Duke and Duchess of Baden; notwithstanding that the 
Prince had done more talking than usual he did not seem at all 
tired in the evening. 

Professor Kiissinaul Summoned. 

February 22. — The Crown Princess informed me that Prof, von 
Bergmann had told her that he was quite sure the Crown Prince 
had cancer of the lungs, and that he should like to have the opinion 
of Prof. Kussmaul of Strasburg. I said I thought this was quite 
unnecessary, as I had examined the lungs carefully myself, and I 
was quite sure that there was no deposit in either of them. Two 
days later Her Imperial Highness again mentioned the subject to 
me, and said she thought it would do no harm for Kussmaul to see 
the Prince. Of course I replied that if Her Imperial Highness 
wished it, I had nothing further to say. Subsequently Prof, von 
Bergmann brought the matter forward at a consultation. I then 
said that I should have no objection to Prof. Kussmaul examining 
the Crown Prince's lungs, but as that gentleman was neither a 
laryngoscopist nor a microscopist, I could not consent to receive 
his opinion as to the nature of the laryngeal affection. 

On this day von Bergmann told the Crown Princess and Count 
Radolinski that the hemorrhage from which the Prince was suffer- 



DR. MACKENZIE' S REPORT. 171 

ing would never cease — that it was in fact the beginning of the 
end. The Crown Princess sent for me to tell me this. I stated my 
belief that by proper management of the tube, when the case was 
again placed entirely in my hands, I should be able to stop the 
bleeding, although it had now become so considerable that I feared 
that under the most favorable circumstances it would probably take 
several weeks to bring about the healing of the ulcers which Bramann's 
canula had caused. Bramann told me this morning in a trium- 
phant sort of way that he had found a great number of cell-nests in 
the sputum, which could only come from a cancerous growth. 
Schrader gave me the same information in the evening, but without 
the same scientific enthusiasm. 

Out for the First Time. 

February 23. — The Crown Prince had had a bad night, but in 
spite of this he said he felt better, and the day being fine he passed 
half an hour out on the balcony. A large number of people as- 
sembled opposite the villa, and greeted the illustrious patient with 
cheers, salutations, waving of handkerchiefs, etc., which appeared 
to give him much pleasure. It had been arranged between Prof, 
von Bergmann and myself that I should now resume charge of the 
case, but Bramann, having requested me to leave the case in his 
hands a short time, as he felt confident he could stop the hem- 
orrhage if he were allowed to manage things in his own way for a 
few days longer, I yielded to his request. The right-angled tube 
which was irritating the anterior wall was taken out, and one of von 
Bergmann's was substituted for it. It was subsequently proved by 
measurements made by Mr. Hovell, that one of the reasons, and 
perhaps the principal one, why the right-angled tube could not be 
worn, was, that the windpipe, as already said, had been opened to 
the right of the middle line. (See p. 178,) 

Schradet 's Misadventure with the Tube. 
During the previous night, Dr. Schrader, who was unfamiHar 
with the construction of Durham's tracheotomy canula, which was 
then being tried, loosened the screw by which the tube is fixed to 
its shield, thereby causing great irritation in the trachea. After he 
had been vainly trying for some time to put things right again the 
Crown Prince wrote on a slip of paper, " Send for Hovell." That 
gentleman soon made the illustrious patient comfortable.* 

* This incident was mentioned in several of tVie French and Italian papers a couple of days later, 
and Dr. Schrader was very indignant with Mr. Hovell and myself for having, as he thought, made 
the matter public. The fact was, however, that the whole story was known throughout San Remo 
the very next morning, A lady confined to her bed in one of the hotels told Dr. Freeman, the pop- 
ular English physician at San Remo, all about it a few hours after it happened. She had learned 
it from a charwoman, who, after doing some rough work at the Villa Zirio in the morning, used to 



172 CASE OF EMPEROR FREDERICK III. 

Hovell Threatened with Imprisonment. 

I may mention here that I constantly received messages from 
Prof. Bergmann through Dr. Schrader as to the necessity of carry- 
ing out the treatment aiitiseptically . This meant dipping the inner 
canula into a weak solution of carbolic acid and water instead of 
cleaning it with plain water. On one occasion Schrader asked me 
to tell Hovell (as the latter did not speak German) that surgeons 
who did not carry out treatment antiseptically were liable to serious 
punishment in Germany, and that recently a surgeon had been sen- 
tenced to three months' imprisonment for neglecting to use anti- 
septic treatment in a case of compound fracture of the arm. I 
pointed out to Schrader that in the after-treatment of tracheotomy 
the use of antiseptics was of little importance, cleanliness being all 
that was required. I said that of course in the case of a wound from 
which, by the use of antiseptics, germs could be excluded, that 
method was of the utmost utility ; but in the case of a canula worn 
in the throat, and necessarily open to the air of the room, the anti- 
septic method could not be applied. He answered that it was Prof, 
von Bergmann's wish that Mr. Hovell should have these directions. 
It appeared to me that the professor of surgery, in the matter of 
antisepticism, attended to the letter rather than to the spirit, and 
whilst insisting on minute observances connected with the instru- 
ments — observances which had been discarded by the inventor of 
the system himself — he did not always perhaps pay sufficient regard 
to personal cleanliness. I afterward told the Crown Prince that I 
had been requested to inform Hovell that he would run the risk of 
spending three months in prison if he did not use carbolic acid freely. 
His Imperial Highness answered with a smile, " If Mr. Hovell is 
sent to prison, I shall have to go there too." 

February 24. — The Crown Prince had a fair night, though the first 
part of it was disturbed by coughing. The removal of Dr. Bramann's 
tube for a few days seemed to have relieved the inflamed part, so 
that when it was introduced it did not at first cause so much irrita- 
tion as before. His Imperial Highness was much depressed during 
the day by the news of the sudden death of his nephew, Prince 
Ludwig of Baden. On this day I learned from two independent 
sources in Berlin, that von Bergmann was sending home most alarm- 
ing letters announcing that the Crown Prince could not live for 
more than a fortnight, and that on the strength of these messages 
many noble families connected with the Court were getting mourn- 

spend the rest of the day at the Hotel des Anglais. The news which this woman learned in the 
morning was all over the town in the afternoon In such ways, many reports, some true and some 
false, got into the newspapers, and thus the wrong persons were frequently blamed for giving news to 
the press. 



DR. MACKENZIE'S REPORT. 173 

ing prepared. I was considerably surprised that a surgeon of any 
experience should commit himself to a gratuitous prophecy which 
there was absolutely nothing in the aspect of the case at that time 
to suggest. 

The Crown Prince's Dislike of Stimulants. 

I now used to have a good deal of conversation with the illus- 
trious patient. I always sat with him at his dinner, or, as it was 
called, supper, and I generally spent half an hour with him whilst 
he was eating his mid-day meal. I may here mention that the illus- 
trious patient's appetite was by no means good, and that he had a 
great dislike of stimulants. He always mixed his wine with water, 
and so little did he care for the flavor of wine, that he always took 
a sip of plain water after drinking it. In reply to a question which 
I ventured to put to him on the subject, he said that he preferred 
being talked to when he was taking his meals, adding that he was 
sure he ate much more heartily when I was with him than when he 
was alone. After this I used to have most interesting conversations 
with the Crown Prince, who had traveled a great deal, and as I had 
done the same, we were able to compare our experiences. He was 
always pleased, too, when I asked about events in the history of the 
House of Hohenzollern, and especially about anything connected 
with Frederick the Great. He was also good enough to answer 
many questions as to his campaigns, and if I did not understand 
him quickly the Prince never minded taking any trouble in writing 
what he wished to say. 

Dr. Bramann told me to-night that nest-cells had again been 
found in the discharge. 

February 25. — The august patient passed a bad night ; his 
digestion was also much disturbed. The large, long tube had again 
set up considerable inflammation in the windpipe. 

Different Ki?ids of Canulas Suggested. 
At about this time I received numerous suggestions from sur- 
geons in England with regard to tracheotomy tubes, and, indeed, 
both at that time and later on at Charlottenburg, after the Berg- 
mann catastrophe, many members of the profession in different 
parts of the world were kind enough to place the result of their 
experience at my disposal. One of our greatest English surgeons 
not only wrote to me, but most kindly sent me apparatus to faciHtate 
the after-treatment of tracheotomy. The laity, especially engineers, 
were fertile in suggestions for warming the air before it passed 
through the canula. The number of tracheotomy tubes that I 
received was quite remarkable, many of them being from patients 
who had been operated on and who were themselves wearing tubes. 



174 CASE OF EMPEROR FREDERICK HI. 

Here I may mention that while I was at Charlottenburg, a French 
gentleman took the trouble to travel all the way from Paris to 
deliver a canula to me personally, and to explain the special 
advantages which it possessed. 

Bergmann's Reports Again. 
On this day I received a letter from Berlin begging for my 
" candid opinion " as to the condition of the Crown Prince. The 
writer gave as his reason for asking the question that Bergmann had 
sent word to Berlin that the illustrious patient was not likely to live 
more than a week, and might die " in four days " ! When I went 
to Berlin in March I found the statements of my correspondent 
confirmed from unimpeachable sources. . It is quite clear, therefore, 
that in the last week of February, Prof, von Bergmann believed the 
end to be very near.^ Whether this idea was based on his erroneous 
supposition that the lungs had been attacked by cancer, and that 
fatal hemorrhage was likely to take place suddenly, or whether he 
had any other ground for the prediction, I cannot say. 

I Propose a New Tube. 
February 26. — The Crown Prince passed a bad night, and 
Bramann's efforts to stop the bleeding proving quite ineffectual, I 
asked to be allowed to insert a new tube made in San Remo of the 
same shape as the one then in use, as far as regards the portion of 
the canula lying external to the trachea, but so constructed that, 
instead of passing a long way down the trachea, it would only just 
enter that tube. My colleagues, however, would not consent to 
this; first, because they considered the lumen of my new instrument 
too small (though it was nine millimetres in diameter), and secondly, 
because it had not an inner tube. This tube would have relieved 
the august patient's sufferings at once, as it was too short to chafe 
the back wall of the windpipe, which was the source of all the trouble 
with the other. Even if a somewhat smaller quantity of air had 
been supplied to the lungs, would not the cessation of the coughing 
and bleeding which prevented the Prince from sleeping have been 
an ample compensation for such a drawback, which after all was 
more or less theoretical ? With regard to the absence of an inner 
tube, such an objection could have been inspired only by the nar- 
rowest surgical pedantry or some less worthy feeling. My impro- 
vized tube was of course only intended as a temporary contrivance 
to be used till a more perfect one could be obtained ; if it had been 
found to answer, a double tube could then have been made to 
pattern. I may add, moreover, that as a matter of fact double 
tubes are a comparatively modern invention, and there are at the 
present moment hundreds of persons wearing single tubes. 



DR. MACKENZIE'S REPORT. 175 

Prof. Bergmann, however, went so far as to tell the Crown Princess 
that with a single tube there would be the greatest danger of the 
Prince being suffocated when the tube was taken out for a few 
seconds to be cleaned. With the most docile and intelligent of pa- 
tients, who had six medical men about him, one or the other of 
whom was always in attendance, it is ridiculous to suppose that 
there could have been any risk in using a single tube for a few days. 
Such, however, were the grounds on which I was prevented from 
affording much-needed relief to the Crown Prince, whose strength 
was being worn out by constant suffering. 

On this day Prof. Kussmaul arrived and took part in the consulta- 
tion this morning. I was not present, as before meeting him, I 
wished to have his position in the case clearly defined. I was willing, 
of course, to receive his opinion on the state of the chest, but not 
as to the larynx, as I did not know that he had any experience in 
the affections of that organ. There had, I considered, already been 
more than enough of such examinations by men whose observations 
could be of no possible value. After making this protest on the 
question of principle, I expressed my willingness to meet Prof. 
Kussmaul as a matter of courtesy. Later in the day that distin- 
guished physician himself called on me, and whilst acknowledging 
that he was not very skilful with the laryngoscope, intimated a wish 
to see what he could of the illustrious patient's throat. 

Kuss?naur s Adventures as a Laryngoscopist. 

February 27. — We all met together for the usual consultation in 
the morning, Prof Kussmaul being present as arranged. After 
making a general examination. Dr. Kussmaul proceeded to inspect 
the larynx. For this purpose he placed the Crown Prince opposite 
the window (though far back in the room), a position in which, when 
artificial light is used, it is very difficult to obtain a good view. 
Seeing that the illustrious professor was quite unaccustomed to make 
a laryngoscopical examination, I arranged the lamp in a suitable 
position, placed the chair differently, warmed the laryngeal mirror 
for him, and assisted him as far as possible. After a long time he 
managed to throw a feeble ray of light on to the mirror, but evi- 
dently did not obtain any view of the interior of the larynx. On 
returning into the next room Prof Kussmaul observed that what he 
had seen reminded him, not of any cases he had previously ex- 
amined, but of a picture of a case of cancer that he had seen in 
von Burow's Atlas ! As it was quite impossible to see into the in- 
terior of the larynx, the swelling of the ary-epiglottic folds com- 
pletely obstructing the field of vision lower down, the value of the 
professor's souvenirs may be gauged. I see from Prof. Kussmaul's 



176 



CASE OF EMPEROR FREDERICK III. 



report in the German pamphlet that he was subsequently instructed, 
and now acknowledges that he only saw the swelling of the ary- 
tenoid cartilages. It seemed to me strange that a man justly dis- 
tinguished for his great knowledge and experience as a general 
physician should condescend to go through the form of making an 
examination with the technique of which he was clearly quite unfa- 
miliar. Such a proceeding hardly seems to be in keeping with the 
recognized character of German science, which is nothing if not 
earnest and thorough. 

Kussmaul Contradicts Bergmann. 
On his own ground, however, the venerable Strasburg professor 
was much more edifying. He absolutely negatived Bergmann's no- 
tion declaring himself unable to find the least evidence of cancer in 
the lungs, or indeed of pulmonary disease of any kind. Bergmann, 
in fact, had been entirely mistaken, and Prof. Kussmaul's journey to 
San Remo had been quite useless.* 

/ have another Tube made. 
February 28. — The Crown Prince passed a fairly good day, but 
the weather was cold, and he did not go out on the balcony. I 
spent most of the day in getting another tube made at a silversmith's 




Fig. II. — The San Remo canula shown in position. The letters a and b refer to 
the gullet and larynx respectively. 

* I was always greatly surprised that Prof von Bergmann could have thought that secondary can- 
cer had formed in the lungs, and I was at a loss to understand why he should be so anxious that 
Prof. Kussmaul should be sent for in order to confirm his e.xtraordinary diagnosis. I was subse- 
quently informed however, that six months previously von Bergmann had seen a case of cancer 
of the larynx with Prof Kussmaul, in which the lungs became affected as a secondary phenome- 
non, and he was evidently of opmion that the sequence which he had once observed was invariable. 



DR. MACKENZIE' S REPORT. 



177 



jt-9w»> 



in San Remo, and Dr. Evans of Paris gave me much valuable as- 
sistance. It was made on the same lines as the one previously con- 
structed, that is to say, it had in part the shape of the German tube, 
but was so short that it would only reach just within the trachea. It 
was constructed so as not to pass down the windpipe at all (see 
Fig. 11), the lower end being cut off in such a way that it was 
parallel to the upper or outer opening, instead of being at right 
angles to it as is the case with most instruments. // was full- sized 
and was provided with an inner tube. 

February 29. — During the early part of the night the Crown 
Prince's sleep was much disturbed, but from four to eight o'clock 

he slept fairly well. There is abundant discharge, 

and it contains a good deal of blood. I noticed 
that the track of the canula, owing to the weight 
of Bramann's instrument was lowering itself, so that 
the San Remo canula had a slightly more horizontal 
position than we had calculated upon obtaining. I 
inserted the new tube just described. 

March i. — The Crown Prince has had a good 
night, and feels much better. He looks stronger 
and says he feels refreshed. The expectoration 
still contains a good deal of blood. His Imperial 
Highness spent a considerable time on the balcony 
to-day. 

March 2. — The Crown Prince had abetter night, 
the cough being much less frequent. There was 
little or no blood in the expectoration, except after 
a particularly violent fit of coughing. His Impe- 
rial Highness spent a good part of the day, both 
morning and afternoon, on the balcony, where he 
ate his lunch. At the morning consultation we 
agreed that it was no longer necessary that one 
of the medical attendants should sit up at night, 
and as the Crown Prince objected to having a 
female nurse. Prof, von Bergmann was requested to 
Fig. 12.— A^sur- §^^ ^^ orderly from Berlin. A day or two later 
gical probe bent the man arrived, and afterward took the nursing at 

at one end at night, 
right angles to 

part die^^ben^ Bramann's Incision, and HovelVs Meastireme7its. 
portion meas- March 3. — -The Crown Prince had a fairly good 
uring just nine night, and the local condition was better." Prof, 
millimetres. Waldeyer arrived to-day, in order to make a micro- 
scopic examination of the material expectorated through the tube. 



178 



CASE OF EMPEROR FREDERICK III. 



Mr. Hovell asked me if he might make some measurements, 
with the view of ascertaining how far Bramann's incision was to the 
right of the middle hne. To this I saw no objection. Mr. Hovell's 
instrument (see Fig. 12) consisted of an ordinary surgical probe, 
bent at one end at right angles to the remaining part, the bent por- 
tion measuring just nine millimetres.* The measurements were made 
in two ways : first, through a straight silver tube,t which was passed 
just to the middle of the trachea ; and second, through the naked 
wound. On introducing the bent probe through the straight canula, 
and turning it to the (patient's) left side, it entirely disappeared 
from view (see Fig. 13), its point barely touching the left wall of 




Fig- 13- — The probe foreshortened and introduced on the patient's left side (^), 
where it disappears, and on the right side (c), where a large portion of it 
remains visible through the canula. The line a b represents the median line of 
the body, and should bisect the circle formed by the orifice of the tube, instead 
of falling considerably to the left of the middle. 



* Nine millimetres was chosen as the length of the arm because the first canula used in making 
these measurements had a diameter of only a centimetre (i e.,ten millimetres), and therefore^ 
longer arm could not be employed. Though the actual tube finally used was nearly 14 mm. in 
diameter, the size of the bent portion of the probe was not altered. 

1 1 had this made for taking tracheoscopic observations The tube was passed just to the orifice 
of the trachea, and then a minute mirror was passed through it, and views obtained above and 
below the tracheal orifice It need scarcely be pointed out that the rough examinations made by 
von Bergmann, and referred to in the German pamphlet, when he merely reflected a ray of light 
into the trachea, were utterly valueless The spot that he saw was simply the posterior wall of the 
trachea opposite the wound ; the bleeding ulcers caused by his long tube (see Fig. 7) were quite 
below the point of vision without a mirror. 



DR. MACKENZIE'S REPORT. 



179 



the trachea. On turning the probe to the (patient's) right side, it 
immediately struck against the right side of the trachea, leaving 
two-thirds, that is, six milUmetres of its length visible (see Fig, 13) 
through the end of the canula. Had Dr. Bramann made the 
incision in the trachea in the middle line, an equal extent of the 
bent portion of the probe (three millimetres) would have been visi- 
ble through the end of the canula (see Fig. 14), whilst six millime- 
tres would have disappeared at the side of the canula whichever 
way the probe was turned. The diagram (Fig. 15) shows a section 
of the trachea; the dark circle representing the canula. It will be 
seen that the centre is nine mihimetres from the right side of the 
trachea and fifteen millimetres from the left side, showing that Bra- 
mann's incision was three millimetres to the right side of the median 
line. The canula was in fact nine millimetres from the left side of 
the trachea and only three millimetres from the right side. Meas- 
urements made through the open wound yielded exactly the same 
results. It may be interesting to observe that other measurements 
showed that the transverse diameter of the trachea was as nearly as 
possible one inch (25 to 26 mm.) This slight deviation from the 
middle line would be a matter of very httle importance, if a 
straight canula could be used, but seeing that for the sake of safety it 
is necessary to have a descending arm, it will easily be understood 



Fig. 14. — Diagram showing how the probe would have appeared on each side if 
the incision in the trachea had been in the median line. 



i8o 



CASE OF EMPEROR FREDERICK III. 




Fig. 15. — Diagram with half of the trachea supposed to be removed, ff^ rep- 
resent the outer walls of the trachea; the other letters are the same as in Fig. 
13. It will be seen that Bramann's incision, instead of being in the median 
line, was three millimetres to the right of it. 

that this descending portion, if introduced shghtly on one side of 
the trachea, is certain to come into contact with its walls, and set 
up great irritation. A moderate-sized tube would have been likely 
to have wounded the walls of the trachea under the circumstances, 
but an enormous tube, such as that used by Bramann, would have 
been sure to have done so. 



The Microscopic Proof at Last. 

March 4. — The Crown Prince had a good night, although there 
was no decrease in the expectoration, which still contained a good 
deal of blood. I covered the canula with a piece of very tight-fit- 
ting india-rubber tubing, so as to prevent the sharp edge accident- 
ally touching the wall of the trachea. Prof, von Bergmann, who 
attended the consultation in the morning for the first time after sev- 
eral days, subsequently introduced me to Prof. Waldeyer, who was 
good enough to show me several preparations which he had made. 
In some of the specimens there was a large number of cell-nests, 
but I did not perceive any alveolar structure. Prof. Waldeyer said 
that although there was no alveolar structure, he considered that 



DR. MACKENZIE' S REPORT. i8i 

from the relation of the nest-cells to one another, he thought it almost 
certain they had come from an alveolar structure. The nest-cells, 
moreover, were so abundant that he thought they could not have 
been produced superficially, but were evidently the result of a deep- 
seated destructive process. As I had always based my diagnosis 
largely on the microscopic character of the disease, I no longer had 
reason to doubt that the morbid process was of a cancerous nature. 
Subsequently Prof, von Bergmann who again came to the con- 
sultation and signed bulletins, called on me and said that the 
Emperor was. very anxious that the Crown Prince should return as 
soon as possible to Berlin. I pointed out that for the illustrious 
patient to return at that season of the year would be likely to be 
injurious to him, but that when the weather became warm I saw no 
objection to his return. Prof, von Bergmann afterward asked me 
to embody my views in a letter, which I accordingly did. 

March 5. — The Crown Prince had a fairly good night, with 
much less cough and expectoration than on any night since the 
operation. His Imperial Highness seemed in very good spirits, 
and his appetite was excellent. He spent a good deal of time on 
the balcony. 

A Treaty of Peace, 

March 6. — Prof, von Bergmann and Dr. Bramann again attended 
the consultation. Prof, von Bergmann brought with him a docu- 
ment which, after undergoing slight modification, was signed by all 
present. It ran as follows : 

"San Reino, March 6, 1888. 

" In view of the rumors circulated in the press about differences of opinion 
among the physicians in attendance on His Imperial and Royal Highness the 
Crown Prince of the German Empire and of Prussia, the undersigned declare 
that there are no differences of opinion among them regarding the nature of the 
disease. Just as little have they maintained that the malady is likely soon to 
take a dangerous turn. The sole responsible treatment is now, as it was before 
the operation, in the hands of Sir Morell Mackenzie. To the newspapers 
of Germany, and other countries, the physicians, in the interest of the illustrious 
patient and of the nations which love and revere him, once more make the 
request that they will refrain from all discussion of the disease, or of the methods 
and instruments used in its treatment. 

"The local affections in and near the larynx of His Imperial and Royal 
Highness have not undergone any essential change. The wound has healed, the 
tube is well placed, the lungs are healthy, the cough and expectoration have 
diminished. The patient's strength is satisfactory; the appetite is increasing; 
there is no disturbance of digestion, pain in swallowing, or headache. Sleep 
lasts unbroken for hours. As Geheimrath von Bergmann's mission is ended, 
he will shortly leave San Remo. " Morell Mackenzie. Mark Hovell 

SCHRADER. VON BeRGMANN. 

Krause. Bramann. 



1 82 CASE OF EMPEROR FREDERICK III. 

The Case is Restored to Me. 

March 6. — The morning being warm and pleasant, the Crown 
Prince for the first time went into the garden. He came down- 
stairs at half-past eleven, took his lunch at one, and returned to 
his room at about half-past two. It was as warm out of doors, if 
not warmer, than in the house, and the illustrious patient greatly 
enjoyed his stay in the garden, where he nearly all the time remained 
seated, occasionally, however, taking a short turn up and down. 

The case was now formally restored to me, but in what a different 
condition was the illustrious patient from what he had been when I 
had given him over to the care of the German surgeons ! On the 
day that he was operated on he felt " perfectly well," except that 
his breathing was difficult ; he was now a confirmed invalid. Be- 
sides this the disease in the larynx which had previously been pro- 
gressing very slowly had, through the coughing caused by ill-fitting 
tracheotomy tubes, been stirred into extreme activity. Greater 
destruction was probably occasioned in three weeks in this way 
than would have occurred in a year had the illustrious patient not 
been subjected to such injudicious treatment. 

March 7. — The Crown Prince has had a good night, and the 
throat feels much more comfortable ; less coughing. 

Serious News from Berlin. 

March 8. — News reached San Remo that the aged Emperor was 
in a critical condition, and a dispatch was received from Prince 
Bismarck urging the immediate return of the Crown Prince. His 
Imperial Highness sent for me, and asked: "Will there be any 
danger in my returning at once to Berlin?" I answered, "Yes, 
sir; there would be some danger;" he then said, "There are some 
occasions when it is the duty of a man to run risks, and such an 
occasion is now before me. I shall return the day after to-morrow. 
I shall be obliged to you to make whatever medical arrangements 
you think necessary, and to confer with Count Radolinski on the 
subject. I look to you to take all steps possible in order to reduce 
the danger of my journey north to a minimum." 

Death of the Empetor Vlilliam. 

The next day news arrived of the death of Emperor William. I 
was not with the august patient at the time, but I was informed by 
an eye-witness that he was greatly agitated on receiving the intelli- 
gence. When I had the honor of seeing His Majesty he was still 
much upset. He spoke little of the event, though it was evident 
that he felt the loss of his aged father much more keenly than 



DR. MACKENZIE' S REPORT. 183 

might have been anticipated considering that the death of a man 
of such advanced age could hardly have been unexpected. Nothing 
better shows how far the character of the Crown Prince stood above 
the ordinary standard of mankind than the fact that the shock of 
his venerable parent's death left no room for some time for any 
other feeling. Private sorrow, however, had to give way to public 
duty ; the responsibilities of his new position had to be faced, and 
Frederick the Third determined to return at once to his own 
dominions. 



CHAPTER XXI. 



CHARLOTTENBURG. 



The New Kaiser's Journey Home. 

On March lo, after a fair night's rest, Frederick the Third left San 
Remo at 9 a. m. There was a slight drizzling rain as we drove to 
the station, but the streets were crowded with people who greeted the 
new Emperor with enthusiasm. During their stay at the Villa Zirio 
the Imperial family had made themselves extremely popular in San 
Remo ; the grand equanimity of the august sufferer had excited uni- 
versal admiration, whilst the gentillezza of the Empress and the young 
Princesses had captivated all hearts. At every station we passed there 
was a vast concourse of people who cheered with a heartiness that 
evidently gave His Majesty the greatest pleasure. During the jour- 
ney the Emperor very frequently invited me into his salon, and I 
had the opportunity of seeing the keen interest he took in the scenery 
in the early part of the journey, and the unspeakable delight which 
he showed the next day when he was once more among his own 
people. His Majesty bore the fatigue of traveling very well, and 
coughed but little ; during the later hours of the day, he occupied 
himself in writing and in arranging various matters with Count Rado- 
linski. He finally retired to rest in his private compartment about 
ten o'clock at night. Mr. Hovell and I slept in His Majesty's salon. 
We reached Munich at half-past eight on the morning of the nth, 
the Queen-Regent of Bavaria meeting His Majesty at the station, and 
passing some time with the Empress and him in their salon. The 
Queen then graciously expressed a wish that I might be presented to 
her, and said to me that she was most agreeably surprised to see the 
Emperor looking so well after all he had lately gone through. 

In the afternoon Count Radolinski showed me an autograph note 
from the Emperor in which His Majesty intimated his wish that I 
should continue to be the chief physician in attendance on his person 



DR. MACKENZIE'S REPORT. 185 

as I had been before he came to the throne, and that Drs. Wegner 
and Krause should see him night and morning, while Prof, von 
Bergmann was to pay him a visit once a week. 

An Interview with Prince Bismarck. 

At Leipzig, Prince Bismarck and several of the great state officials 
paid their respects to the new Emperor. After his audience with 
His Majesty, the Chancellor expressed a desire to have some con- 
versation with me, and I accordingly traveled in the same carriage 
with him to the next station. Prince Bismarck said he was most 
anxious that the Emperor should be spared all unnecessary fatigue, 
and requested me to lay down rules as to the number of interviews 
which His Majesty might safely grant each day, the duration of such 
interviews, etc. I informed the Chancellor that I had already drawn 
up some rules of the kind, which I had given to the Hof- Marshal. 
Prince Bismarck further said he would be glad to assist me in every 
way to save the august patient all worry and fatigue, adding, that 
until the foreign princes arrived to be present at the Emperor 
William's funeral, His Majesty could remain perfectly quiet. 

Arrival at Charlottenbiirg. 

We reached Charlottenburg at eleven o'clock at night in a blinding 
snowstorm. The Emperor was received by the Crown Prince and 
other members of the Imperial family, and drove at once to the 
Schloss. The intense whiteness of the streets and houses, the 
briUiant illuminations, and the enthusiastic crowds of people, made a 
very striking picture, and as we drove up to the castle gates, the 
Garde du Corps, with their eagle-crested helmets, glittering cuirasses 
and drawn swords, added to the imposing nature of the scene. His 
Majesty alighted from his carriage with a firm step, and in passing 
through the hall, spoke to the British Ambassador and several high 
officials who were there. He very soon retired to his room, where I 
followed him and found him rather fatigued by the journey. The 
shaking of the railway carriage had slightly increased the discharge 
from the canula, but on the whole he had borne the excitement 
remarkably well. 

His Majesty had a good night, and on the morning of the 12th I 
was pleased to find that the journey had done him little or no harm. 
He was very slightly feverish, the temperature being 99*2, and the 
pulse 76, but otherwise his condition was relatively satisfactory. I 
should mention here that His Majesty's natural pulse was rather slow, 
its average number of beats each minute being only 64. There was 
little or no change during the next two days. 



i86 CASE OF EMPEROR FREDERICK III. 

Threatening Letters. 

On March 14, 1 received several threatening letters. In one of 
them the writer informed me that he was one of a band of ten who 
had agreed to sacrifice their own lives in order to take mine. They 
had drawn lots, and to my correspondent it had fallen to make the 
attempt first, and if he failed, his companions would take his place 
one after the other, till the deed was done. He added, that if I did 
not leave Germany by March 17, my life would not be worth an 
hour's purchase. In two of these interesting epistles, it was declared 
that a German Emperor should be treated by none but German 
doctors. These threats seemed to be the direct result of the trucu- 
lent articles which appeared day after day in certain newspapers 
which made it a point of national honor to support the German 
doctors through thick and thin. I believe it was the Kolnische 
Zeitung that said that " Mackenzie dared not let himself be seen in 
Unter-den-Linden," the principal street in Berlin, " because if he 
showed his face there the people would tear him in pieces or stone 
him to death." This is the paper whose Berlin representative — a 
certain Dr. Fischer — for many months systematically supported von 
Bergmann and vilified me. He made me the object of these polite 
attentions as far back as May, 1887, when he asserted that the oper- 
ation I had succeeded in doing, was really performed by Tobold, the 
specialist who " no longer operated ! " Some days later (March 17) 
I was offered pohce protection, and subsequently I was frequently 
asked when I was going out, whether I should like to be accompanied 
by a detective. This I invariably declined. 

The Windpipe Crumbli7ig Away. 

On March 15, a large slough came away from the upper and 
deepest part of the wound. It seemed to consist of broken-down 
tissue — mainly minute pieces of cartilage — from the trachea. This 
destructive process was no doubt the consequence of the pressure of 
the large and unsuitable tube which had been the source of so much 
suffering to the august patient at San Remo, and which he had con- 
tinued to wear till I was permitted to introduce the roughly improvized 
Itahan canula. The ettect of the separation of the slough was con- 
siderably to enlarge the opening into the windpipe, the vertical 
diameter of which was now rather more than two centimetres (four- 
fifths of an inch). The upper part of the tracheal orifice was nearly 
on a level with the wound in the skin, instead of being a good deal 
below it as before. 



DR. MACKENZIE' S REPORT. 



Funeral of the Emperor William. 



187 



On the morning of the same day (March 15) the Emperor had 
received visits from the Kings and other royal personages who had 
come to attend his father's funeral. His Majesty asked me if it 
would be possible for him to take his place at the mournful cere- 
mony, but I was obliged to inform him that in the state of health he 
was in, the emotional excitement inseparable from the occasion, to 
say nothing of exposure to the bitter weather which then pre- 
vailed, would make such a step in the highest degree dangerous. 
For once the Imperial sufferer appeared to be unwilling to obey my 
injunctions ; he begged hard to be allowed to pay the last tribute of 
respect to the venerable parent by whose deathbed he had not been 
able to stand, and it required all the firmness I could command to 
induce him to give way. The funeral took place on the 16th, and 




Fig. 16. — Durham's tube zw situ and acting well. 

His Majesty was more depressed than I had ever seen him. His 
countenance expressed the deepest sorrow; he was restless and 
agitated, and twice he pointed to a window looking toward Berlin, 
saying, "/ought to be there! " 

A more comfortable Tube. 

On March 16, finding that the separation of the slough had not 
been followed by any tendency to hemorrhage, I determined once 
more to try the effect of a Durham's tube, which now passed easily, 
and could remain fixed in a horizontal position. (See Fig. 16.) The 



1 88 CASE OF EMPEROR FREDERICK III. 

canula introduced by Bramann having caused such extensive erosion 
of the mucous membrane of the windpipe with so much local inflam- 
mation, I had not ventured before this to use a tube which passed 
down the trachea. The insertion of the new instrument was borne 
very well by the Emper£)r, the temperature remaining normal. 

The next day His Majesty was able to receive a large number of 
distinguished personages who came to pay their respects to him 
before leaving Berlin. I found that the new tube had caused some 
bleeding, which, as my note-book states, was " more this morning 
than it has been since leaving San Remo," There is no doubt that 
this was due to the softened and irritable condition in which the lin- 
ing membrane of the windpipe had been left by the first canula. 

On March i8, I was gratified to find there had been less bleeding. 
I shortened the horizontal portion of the tube (by moving the shield) 
to the extent of one centimetre, and twisted its lower ejid slightly 
to the left so as to remove its edge from the right wall of the trachea. 
(See Fig. 17.) The Emperor attended prayers in chapel this morn- 
ing, and it was noticed that he did not cough once during the ser- 
vice. His Majesty received the special envoys and the whole diplo- 
matic body, the audience lasting an hour and a quarter. In the 
evening the Duke of Cambridge paid a visit to the Emperor. 

The Imperial Invalid's Daily Life. 

The weather was still very severe, snow falling almost continuously. 
At this time the illustrious patient's course of life was as follows : 
He generally rose soon after eight, after breakfasting in bed, and 
was dressed by half-past nine. He then went down to the Orangery, 
where the Empress accompanied him, whilst I remained near at 
hand. About ten o'clock His Majesty returned to his study, where 
he gave audiences to his ministers and other officials till noon. Soon 
afterward he used to go again to the Orangery, where he remained 
for an hour or so, sitting in the central pavilion, or walking up and 
down the long corridor. Here also the Emperor often received 
visitors and officials. Though the Orangery was better than nothing, 
it was a very depressing place after the bright sunshine and balmy 
air of San Remo ; the building had not originally been constructed 
as an Orangery, and the glass work occupied only one side. The 
orange trees were old, thick-stemmed, and covered with leaves, so 
that the interior was very gloomy. After lunch the Emperor gener- 
ally saw some members of his family, after which he rested for an 
hour or two. Before, or after taking his rest, His Majesty often 
received Prince Bismarck or the Crown Prince. After his siesta the 
Emperor generally attended to state business, signed papers, and 



DR. MACKENZIE' S REPORT. 



189 



<V, 




Fig. 17. — Durham's tube (full size). It is twisted slightly to the (patient's) 
left side, to avoid the right wall of the trachea. Compare Figs. 13, 14 and 15. 

wrote his diary. He dined at eight, and went to bed between half- 
past nine and ten. 

The Question of Operation iti a New Aspect. 

As the health of the Imperial sufterer had by this time somewhat 
recovered from the effects of the rough handling to which his 
wounded throat had, in spite of my protests, been subjected at San 
Remo, the question arose in my mind whether a radical operation 
should now be proposed to His Majesty. I had resolutely set my 
face against any such measure when there was still a doubt as to the 
nature of the disease ; but since Prof. Waldeyer had pronounced it 
to be cancer, the situation was entirely changed. The only hope of 
cure lay in removal of the disease. It was a very forlorn hope, 
no doubt, and one more than counterbalanced, to my mind, by the 
immediate risk of the operation, and the wretched condition in which 
those who survive it are almost invariably left, owing to the dreadful 
mutilation they have undergone. Moreover the chances are always 
enormously in favor of a recurrence of the disease within a very few 
months. The results of complete extirpation of the larynx have 
hitherto been so bad (see Table III., p. 276), that some practitioners 
are doubtful whether so deadly an operation has any place in legiti- 
mate surgery. My own opinion, however, is that, fatal as this opera- 



igo CASE OF EMPEROR FREDERICK III. 

tion has proved to be, a greater number of patients are cured by it 
than by what is miscalled " simple thyrotomy." The immediate mor- 
tality from the operation is 36-23 per cent., thirty-six patients dying 
within nine days ! Still 8 cases out of 138 are said to have been 
cured by this operation ! On the other hand, it is certain that not a 
few of the fatal or unsuccessful operations carent vate sacro, and are 
not allowed to appear in published statistics. If the record were com- 
plete, the results would probably deter the boldest surgeon from at- 
tempting a procedure in which, as Dr. Paul Koch * has said, it is a 
triumph for the operator if the patient does not actually die under 
the knife. 

Nevertheless, as the operation does give the patient a chance — in- 
finitesimal though it be^ — and the disease is absolutely incurable by 
any other kind of treatment, I thought it right to discuss with Prof. 
Krause and Mr. Hovell the propriety of mentioning the matter to 
the Emperor. These gentlemen fully agreed with me that after all 
the august patient had gone through since tracheotomy had been 
performed, any severe surgical measure was out of the question. It 
is certain, however, that even at that time the operation, qua opera- 
tion, which would have been perfectly feasible, because after death the 
anterior wall of the gullet was found to be intact, and the ulcer could 
have been dissected away from the posterior wall of the larynx, the 
oesophageal tube being still left in a state of integrity. Or, if that 
had not been found feasible, a portion of the oesophagus could have 
been cut out, as is usually done in these operations. I am far from 
saying that even if the illustrious patient had been in a state of health 
to admit of extirpation of the larynx, I should have urged him to 
submit to it, but I maintain that had it not been for the unfortunate 
mismanagement of the case by Drs. von Bergmann and Bramann in 
February, the operation might possibly have been undertaken when 
the nature of the disease had been definitely estabhshed by Prof. 
Waldeyer. 

It is beyond all question that the disease made much more rapid 
progress after the tracheotomy than before. As a rule, that operation 
has quite the opposite effect, for it gives the diseased parts compara- 
tive rest, and so far saves them from irritation. Why was the result 
so wofully different in the present case ? Because the violent shaking 
of the larynx broke down the tissues, and caused as much destruction 
in a few weeks as is ordinarily produced by the unassisted action of 
the disease in many months. What was this shaking of the larynx 
due to ? To the violent and almost continual coughing, set up by 
the chafing of the delicate inner wall of the windpipe by ill-fitting 
tracheotomy tubes. Later on, as will be told in due course, a further 

* " Annales des Maladies de I'OreiUe, etc.," March, 1879. 



DR. MACKENZIE'S REPORT. 191 

source of irritation was supplied by the trickling into the windpipe 
of matter from an abscess caused by Prof, von Bergmann's blunder- 
ing efforts to make force supply the place of skill in introducing a 
canula. 

The Bleeding Stopped at Last. 

In the meantime, as I have said, the ill-used trachea had, under 
more intelligent management, had some chance of recovering to a 
certain extent. From March 19 to the 2 2d, there was comparatively 
little coughing, and hardly any bleeding. His Majesty slept fairly 
well at night, and the temperature remained almost normal. It was 
only three weeks since I had been allowed to insert the tube I had 
had made at San Remo, and the bleeding, which till then had been 
all but continuous, had now almost ceased ! It must be understood 
that the loss of blood was much greater than would be gathered from 
the euphemistic " blood-stained expectoration " of the bulletins. It 
was real hemorrhage, slight, it is true, but almost constant, so that a 
considerable amount of blood was lost each day. After March 22 
there was no further bleeding, except once or twice after massage 
had been performed, and a very slight attack on March 31. This 
gratifying result was entirely due to the substitution of a proper tube 
for the instrument of torture which had wrought all the mischief, and 
is therefore a significant commentary on the assertion repeatedly made 
by von Bergmann, in the most emphatic terms, that no matter what 
tube was used the bleeding would never cease. (See p. 170.) 

Another " Cofitroller" 
About this time I discovered that I had again been placed under 
" control " — on this occasion by Prof, von Bergmann. I learned 
that the orderly in attendance on the Emperor was in the habit of 
making daily reports to Bergmann, who had, as a matter of fact, 
engaged him, of everything that took place whilst he was on duty. 
This arrangement was no doubt only an additional proof of the 
absorbing interest which Prof, von Bergmann took in the illustrious 
patient's condition. Although many physicians in my place would 
no doubt have strongly objected to reports being made behind their 
backs by a servant to a colleague engaged in the case, I did not think 
it worth while to take any notice of the matter, especially as the man 
did his work satisfactorily in other respects. On the whole I pre- 
ferred his "control" to Landgraf's; his "observations" were no 
doubt just as accurate, and he did not insist on using the laryngo- 
scope. I cannot say, however, that I admire the system of medical 
police supervision to which I was subjected ; it may be useful for 
insuring a copious supply of " official sources," but it is insulting to 
the physician, and might easily be injurious to the patient. 



192 CASE OF EMPEROR FREDERICK III. 

The Wiesbaden Project. 

Before the Emperor came to Berlin, there had been some question 
of his going to stay at Wiesbaden for a time, for the sake of quiet 
and the comparative mildness of the climate. During the first fort- 
night of His Majesty's residence at Charlottenburg this project was 
often discussed, but as at the time the whole of Germany was deeply 
covered with snow, there did not seem to be any advantage in his 
leaving Berlin. Indeed only the sternest necessity would have induced 
me to consent to the Emperor's undertaking any journey whatever at 
that time. 

Further Disifitegration of the Windpipe. 

On March 23, fresh evidence was supplied of the havoc which had 
been wrought by Bramann's tube. During the preceding night the 
Emperor had had several severe attacks of coughing, which came on 
at intervals of an hour or two and lasted for a considerable time. On 
removing the tube in the morning a flat, quadrilateral piece of car- 
tilage about twelve millimetres long, and from six to seven millimetres 
wide, was found loose in the upper part of the tracheal opening. Prof. 
Hartmann, to whom it was sent for microscopic examination, pro- 
nounced it to be a piece of hyaline cartilage, which had no doubt 
come from the windpipe. It represented about a sixth part of one 
of the tracheal rings. 

Massage 7 Vied. 

At the general consultation on the same day, it was agreed that as 
the Emperor was confined to the house by the very severe weather, 
and was suffering from the want of exercise, massage should be tried 
as the best available substitute. On the recommendation of Prof, 
von Bergmann it was decided that the manipulations should be car- 
ried out by Dr. Zebludowsky, As massage had not yet quite found 
its level among our therapeutic resources, being vaunted as a panacea 
by some and despised as quackery by others, it may be right for me 
to point out the precise object for which it was proposed to apply it 
in the present case. There was of course no idea that it could have 
any effect on the disease, but it was thought it might be useful 
as giving passive exercise to the muscles, and stimulating the vital 
functions which the enforced bodily inactivity was making torpid. 
Men of stalwart frame who have been accustomed to an outdoor life 
involving much physical exertion, always suffer greatly from want of 
exercise, and His Majesty was no exception to this rule. Massage 
was applied on two or three occasions with great skill by Dr. Zeblu- 
dowsky, but it was found that it did not suit the illustrious patient, as 
it over-excited him, and caused some fresh bleeding from the throat. 
It was therefore decided to discontinue it. 



DR. MACKENZIE'S REPORT. 193 

Honors Gracefully Conferred. 
On March 25, the Emperor put into Dr. Krause's hands a docu- 
ment appointing him an Extraordinary Professor in the University of 
BerUn. The title of Professor has fallen to such " base uses " in this 
country that, as Matthew Arnold pointed out, learned men are gen- 
erally rather shy of claiming it. In Germany, however, the use of 
the title is so strictly regulated that the possession of it is an honor 
which is greatly coveted ; it also makes an immense practical differ- 
ence in a professional man's position. At the same time His Majesty 
handed me a slip of paper of which the annexed sketch is a fac- 
simile reproduction. 




t^ G\r\ji>XMr^'^-^ fXs-'i^^ 











194 



CASE OF EMPEROR FREDERICK III. 




(9f/''V-ff--?-/H. ^ 




^ M AiVsTV- ^IPok) a>t^ 





^^-4-I«'wl»0t/t<..^/X!) 



This communication is very characteristic of Frederick the Noble, 
showing as it does his profound respect for the Queen, and his deli- 
cate thoughtfulness for humble individuals like myself. I know of 
no other instance in which a foreign monarch has, before conferring 
an honor on an Enghshman, not only taken the trouble to ascertain 
whether the distinction would be pleasing to the recipient's own 
sovereign, but obtained leave for him to accept and use it. Honors 
thus conferred are something immeasurably beyond the mere title or 
insignia which represent them ; they become precious marks of graci- 
ous personal interest like the gifts of an attached friend. 

Attacks by the " Reptile " Press. 

From about this time I was made the object of constant attacks in 
some of the German newspapers which seemed to draw their inspira- 
tion largely from Prof, von Bergmann ; conspicuous among these 
were the Kohtische Zeittmg, the Kreuz Zeitung and the Post. A 
large number of provincial papers took their cue from these jour- 
nals, and abused me with a virulence of which English people 



DR. MACKENZIE'S REPORT. 195 

can scarcely form an idea. Threatening letters came to me in shoals, 
but I am happy to say I also received many messages of sympathy 
and encouragement ; whilst the former all emanated from one clique, 
the latter were sent by representatives of all classes, the aristocracy, 
professional men, merchants, tradespeople and workingmen. These 
kind and encouraging letters will always be kept by me amongst my 
most prized possessions, as delightful souvenirs of a most trying time. 
It is amusing, but at the same time somewhat painful, to note, as 
showing the depths of malignant stupidity to which men may fall 
when misled by passion, that one of the chief grounds of attack 
against me was the alleged fact that I was of Jewish origin. When 
argument and invective were exhausted, the appeal to the anti-Semitic 
feeling so prevalent among certain classes in Germany was a never- 
failing resource. My real name was said to be " Moritz Markovicz," 
of which hypothetical appellation " Morell Mackenzie " was gravely 
said to be the EiigUsh equivalent. Quite recently (August 31) I was 
favored with an advertisement taken from an illustrated German 
paper, in which my portrait was promised for an early number in the 
following terms : " VVe shall also lay before our readers an account 
of the goings-on of that Jewish-English horror Markovicz alias Mac- 
kenzie, and as a proof that the so-called Englishman is really a Jew we 
shall publish his portrait after a cabinet photograph." This interesting 
work of art has since appeared, and I observe that my " innocent 
nose " has been somewhat cruelly aggravated into a formidable append- 
age of the caricature Hebraic type. The descriptive letter-press is 
worthy of the picture. My parentage is thus spoken of : " Our readers 
will remember that it was stated in many quarters that the grandfather 
of this so-called EngHshman was a Polish Jew of the name of Marko- 
vicz, who left Posen and settled in England. This man (Morell 
Mackenzie), who denies everything, has never denied this. The 
name of Markovicz was afterward changed to Mackenzie." My 
respected grandfather, who was extremely proud of his Highland 
descent, and who never set foot outside the United Kingdom, would 
doubtless have been surprised to hear that he was a Polish Jew ! A 
correspondent wrote to me from Dantzig, " It is no good for you to 
pretend that you are not a Jew. You encouraged a Jewish doctor 
from this town to settle in London, a thing which nobody but one 
of the tribe would have thought of doing." Even persons profess- 
ing to be my friends exhibited a lively curiosity as to my origin. A 
lady wrote to me from Magdeburg, saying that she had defended me 
on every point, except as to the question of my Jewish faith. If I 
could only give her some evidence to show that I was not a Jew, 
she thought things would be more comfortable in that town. She 
would be glad to know where I was born, and where my ancestors 



196 CASE OF EMPEROR FREDERICK III. 

came from. I need not say that if I really did belong to the 
remarkable race which has produced so many men of the highest 
distinction in every department of literature, art, and science, so far 
from being ashamed of such an extraction I should be proud of it. 
I have only thought it worth while to notice the matter merely as an 
example of the gross inaccuracy of statement which, not less than 
systematic scurrility, has been the distinguishing feature of the attacks 
on me. These absurd attacks are of course utterly unimportant in 
themselves, but they serve to show the character of the people who 
supported Prof von Bergmann. That gentlemen's journalistic friends 
not only denied that I did the Emperor any good, but accused me 
of preventing their protege from using his skill to relieve the illus- 
trious patient. 

Out of Doors Again. 

On March 28, the Emperor was able to go out for the first time 
since his return to Germany. The weather was bright, and His 
Majesty walked for some time in the open air outside the Orangery. 
On the 29th (Maundy Thuraday), the Emperor, together with the 
Empress and the rest of the Imperial family, took the Holy Com- 
munion, and His Majesty afterward went for a drive in an open car- 
riage to the Griinewald forest. He wore the ample blue cloak of the 
Prussian cavalry, with fur cape and field cap. I followed in a car- 
riage with one of the adjutants. In the afternoon His Majesty 
walked in the garden and in the park. 

The next day, as the sun was shining brightly, I said to the Em- 
peror: "A fortnight ago, sir, you asked me if you might drive into 
Berlin to pay a visit to Her Majesty the Empress Augusta, and I felt 
obliged to tell you that it would be dangerous for you to leave the^ 
house. To-day, I think you may safely go." The Emperor's face 
beamed with pleasure, and he shook me warmly by the hand, say- 
ing, "I am, indeed, delighted." This was the first time he had visited 
his capital since his return. His appearance there was quite unex- 
pected, and accordingly the police had made no arrangements for the 
preservation of order. He was received with such enthusiasm that I 
felt rather alarmed lest the excitement might be too much for him, 
but he bore it well, and seemed as glad to be among his people as 
they were to see him. It was sad, however, to think of the stricken 
Kaiser in the midst of that seething sea of vigorous life. I was 
agreeably surprised on this occasion to find that, in spite of all the 
abuse which I had received from a section of a German press, and 
the threatening letters which had poured in upon me since I had 
been at Charlottenburg, the Berlin people seemed very well dis- 
posed toward me. The men took off their hats, and the ladies 



DR. MACKENZIE'S REPORT. 197 

bowed to me in a friendly way. On returning to Charlottenburg, 
His Majesty did not seem at all tired, and was able to walk in the 
garden for some time in the afternoon. Two days later the Emperor 
paid a second visit to Berlin. 

Progress of the Disease. 

On April 3, His Majesty said he felt better than he had done since 
the operation. He was able to dress himself almost without help. 
His temperature, however, was higher that evening than it had been 
for some time, reaching 101° Fahrenheit, whilst his pulse was 86. 

Prof. Esmarch, of Kiel, visited the Emperor on this day, and 
afterward had some conversation with me. He urged me to give 
the Chian turpentine treatment a fair trial, saying that in two cases of 
cancer under his own care it had done a great deal of good. I 
informed him that it had already been tried in the Emperor's case. 

On April 4, the temperature was still rather high, and the illustri- 
ous patient had been much troubled with cough the night before. 
On the 5th, a good deal of disorganized tissue came away from the 
right side of the opening in the windpipe, and some vegetations 
were noticed around the latter. These were touched with nitrate of 
silver, which, however, only made them look " angry " and inclined 
to bleed. The next day the upper part of the wound and the chan- 
nel of the windpipe above the tube was seen to constitute a solid 
arch of morbid tissue ; whether this was new growth or simple 
inflammatory swelling it was impossible to say. There was inflam- 
mation of the areolar tissue above and at the sides of the wound, 
and at the orifice of the trachea. His Majesty also complained of 
some pain in swallowing ; this appeared to be due solely to the 
inflamed condition of the trachea, which is, of course, pulled upward 
in deglutition. The Emperor also suffered from headache, which 
was, however, relieved by the remedy which generally proved 
effectual in his case. 

It was only too clear that the whole structure of the windpipe in 
the neighborhood of the wound was falling to pieces. On April 10, 
two large fragments of cartilage came away, and the trachea began 
to lose its rigidity. There being hardly any cartilage left in front to 
support the tube, the latter lay loose in the wound, and the back wall 
of the trachea tended to fall forward so as partly to cover the inner 
end of the tube. 

At this time there was a good deal of excitement in the public 
mind about the proposed Battenberg marriage, but I cannot say that 
it produced much effect on the Emperor. 



198 CASE OF EMPEROR FREDERICK III. 

My Visit to London Postponed. 

It had been arranged some time previously that about this time I 
should be allowed to return to London for a week or two, and as 
there were no symptoms indicative of impending danger, I was look- 
ing forward to my brief holiday with some pleasure. The Emperor, 
however, said to me one evening, " I hope you won't mind putting 
off your return to London for a short time." He continued, "I 
expect your patients in London must quite hate me for keeping you 
here." I replied, " No sir. All English people take the deepest 
interest in your health. There is no one who would not make sacri- 
fices to be of service to you." His Majesty replied, " I cannot 
understand why it is that people are so kind to me." In the evening 
the Emperor sent for me and handed me the Cross and Star of the 
Hohenzollern Order, together with an autograph letter, of which the 
following is a copy : 

" Charlottenburg, April 10, 1888. 
"My Dear Sir Morell, 

"You were called to me by the unanimous wish of my German medical 
attendants. 

"Not knowing you myself, Iliad confidence in you in consequence of their 
recommendation. But I soon learnt to appreciate you from personal experience. 

" You have rendered me most valuable services, in recognition of which, and 
in remembrance of my accession to the throne, I have the pleasure to confer 
on you the 'Comthur Cross and Star of my Royal Order of Hohenzollern.' 

"Yours truly, 

" Frederick, I. R. 

" Sir Morell Mackenzie." 

Mr. Hovell received at the same time a high order from His Ma- 
jesty — the Second Class of the Kron Order. 

A Fatal Day. 

As, owing to the unfortunate series of events which occurred 
on April 12, that day proved to be a turning-point in the case, I need 
make no apology for describing what took place at some length. 
Before doing so, I may be allowed to say that what I am about to 
state here is the exact truth to the best of my knowledge and belief. 
There has been so much misrepresentation and downright lying about 
this matter, and the consequences of what occurred were so serious, 
that it is necessary to place the whole body of facts before my readers 
in order that they may be in a position to form a correct judgment. 
Let it be understood, that if I seem to express myself strongly it is 
only because I feel strongly ; if I have "nothing extenuated," at least 
I am not conscious of having " set down aught in malice." 



DR. MACKENZIE' S REPORT. 199 

On the night of April 11-12 the Emperor was seized with severe 
coughing between midnight and i a. m. At 1.30 Mr. Hovell noticed, 
that although air passed freely through the canula, the breathing was 
accompanied by a noise as if there were something projecting below 
the lower end of the tube. On removing the canula the noise 
ceased — a circumstance which caused Mr. Hovell to think (and this 
view I afterward confirmed) that the lower edge of the posterior part 
of the canula must slightly press into the posterior wall of the trachea, 
owing to its bulging forward at that part. This latter view was sup- 
ported by the fact that the external part of the canula was pushed 
forward. Mr. Hovell slanted the tube rather more away from the 
right side, and inserted a pad under the lower edge of the shield so 
as to tilt the lower and back edge of the canula away from the pos- 
terior wall. The noise was somewhat less after this was done, but did 
not entirely cease. The Emperor also breathed a good deal more 
quickly than usual. At 2.15 a. m. Mr. Hovell was again called, but 
found no change. At 2.40 he returned to the illustrious patient, not 
having gone to bed in the meantime, and found him in precisely the 
same condition. Mr. Hovell was summoned several times afterward 
during the night, and on more than one occasion he slightly altered 
the position of the tube by placing pads under the shield. At 8 a. m. 
I saw the Emperor, and as the breathing, though quickened and 
slightly noisy, was quite free, I determined to leave the canula in situ 
till Drs. Krause and Wegner arrived. At the consultation it was 
agreed to try the effect of a shorter tube. His Majesty appeared to 
breathe perfectly well as soon as this tube was introduced, but about 
half an hour afterward the respiration again became rather noisy. I 
therefore removed the short tube and replaced the former one. As 
there was no urgency whatever, and as, in anticipation of some trouble 
of the kind, I had ordered several special tubes in Berlin three days 
before, I thought it would be better to go and fetch these canulas 
rather than try any of those I had by me. Finding, however, that 
the tubes were not quite ready, I directed one of a suitable shape to 
be quickly made of lead, and asked the instrument- maker to come to 
Charlottenburg at once, so that if the first tube did not answer, a 
second could be made on the spot.* As the tube which I now 
proposed to try was different in shape from any of those which had 
been used since the case had been formally given up to me by Prof, 
von Bergmann at San Remo, I thought that professional courtesy re- 
quired that I should ask him to be present on the occasion. As I 
intended to do whatever was necessary with my own hands, there 



* The advantage of lead is not only that it can be very quickly made, but that the curve of the in- 
strument can also be readily altered. For a short time a tube of this material answers perfectly 
well. 



200 CASE OF EMPEROR FREDERICK III. 

was really no need for the assistance of a surgeon, but it is an ele- 
mentary rule of civilized medical practice that all those associated 
together in the management of a case should be made acquainted 
with the details of the treatment that is carried out. As soon as the 
new tube was ready, therefore, I despatched a messenger to Prof, 
von Bergmann, to request him to come to me as soon as possible, 
meaning of course that I was anxious to proceed to change the tube 
without delay. 

In sending off that message, little did I think that it would have such 
fatal consequences. It is no exaggeration to say that these hastily 
scribbled lines proved to be the death-warrant of the Emperor. 
Had I had the slightest idea of what was to follow, I should certainly 
not have allowed any over-punctilious notions of etiquette to mislead 
me into taking so disastrous a step. At the moment, however, it ap- 
peared to be the right thing to do. The Emperor on his accession to 
the throne, had appointed Prof, von Bergmann to be one of his medi- 
cal attendants no doubt in deference to public opinion in Germany, 
and I had been repeatedly and urgently requested by the chief officer 
of His Majesty's household. Prince Radolin, to endeavor to work 
harmoniously with von Bergmann, who. Prince Radolin assured me, 
was "greatly trusted by the official classes." Hence my anxiety 
that there should be no ground for complaint, so far as I was con- 
cerned, of any violation of the decencies of professional intercourse. 

It was five o'clock in the afternoon before Prof, von Bergmann 
arrived. As soon as he came into my room, I noticed that he was 
in a state of great excitement ; whether this agitation was due to 
exaggerated reports which he may have received as to the Emperor's 
condition, or to causes of a more personal nature, I am unable to 
say ; but either from over-excitement or from some other cause, 
Bergmann behaved in a most extraordinary, indeed altogether unac- 
countable, manner. 

I briefly explained the circumstances, and showed him the tubes 
which I had got ready, though Bergmann seemed in too great a 
flurry to be able to listen attentively. We then proceeded to the 
Emperor's room, accompanied by Mr. Hovell, each of us carrying 
several tubes. We found the Emperor engaged in writing. The 
inspiration was distmctly audible, but beyond this there was not the 
slightest indication of any difficulty in breathing. Prof, von Berg- 
mann placed a chair opposite the window, and asked the Emperor to 
sit down upon it; and thereupon, without making any remark, he 
quickly undid the tape which kept the canula in position, pulled the 
latter out, and, with considerable force, endeavored to insert one 
which he had in his hand, and which was not provided with a pilot. 
The instrument was forced into the neck, but no air came through it. 



DR. MACKENZIE'S REPORT. 



The Emperor's breathing thereupon became very much embarrassed, 
and the professor withdrew the tube. This was followed by a violent 
fit of coughing, and there was considerable hemorrhage. Prof, von 
Bergmann next seized a tampon-canula covered with sponge, cut the 
sponge quickly off, and then tried to push the tube into the wind- 
pipe. Again no air came through the canula, and it was clear that 
instead of entering the air-passage it had been forced downward in 
front of the trachea, ploughing up the soft tissues in that situation, 
and making what is technically known as a " false passage." Again 
the professor had to pull out the tube, and again its withdrawal was 
followed by violent coughing and streams of blood. To my 
consternation, Prof, von Bergmann then pushed his finger deeply 
into the wound, and on withdrawing it tried to insert another tube ; 
he again failed, however, and again the attempt was followed as 
before by most distressing coughing and copious bleeding. The 
position of the canula as introduced will be understood by ex- 
aming Fig. i8. Prof, von Bergmann then asked that his assistant, 
who was waiting in his carriage outside, might be sent for. It 




Fig. i8. — Diagram (half size) showing the part into which von Bergmann 
plunged the canula. The instrument, instead of being in the trachea, is seen 
to be in front of it. 

seemed as if he contemplated doing some further operation, per- 
haps enlarging the wound ; but the Emperor was saved any further 
torture by the arrival of Dr. Bramann on the scene. Prof, von 
Bergmann at once yielded the case into the hands of his assistant, 



202 CASE OF EMPEROR FREDERICK III. 

and the young surgeon, taking a moderate-sized canula (No. 8 
German measure), passed it with the greatest ease into the trachea. 
There had, indeed, never been any difficulty in introducing the 
canula. I had inserted a tube in the presence of my colleagues, 
Drs. Wegner and Krause, at lo o'clock that morning, and I sub- 
sequently took it out and substituted another for it. Although both 
these tubes had passed quite freely and without causing either 
coughing or bleeding, neither of them was altogether satisfactory, 
and other canulte had, therefore, to be procured. The Emperor 
coughed almost incessantly, and continued to lose much blood for 
two hours after Bergmaiin's abortive struggles with the tube ; the 




Fig. 19. — Diagram showing von Bergmann's "false passage." c is the proper 
track of the canula ; d, the black part, shows tlie false passage. 

severity of the symptoms then began to diminish, but there was 
still a good deal of coughing with some hemorrhage at intervals, 
till His Majesty went to bed. 

Half an hour after the professor's departure, the Emperor sent 
for me and asked, " Why did Bergmann put his finger into my 
throat ? " I replied, " I do not know, sir." His Majesty then 
went on to say, " I hope you will not allow Prof, von Bergmann to 
do any further operations on me." I answered, " After what I 
have seen to-day, sir, I beg most respectfully to say that I can no 
longer have the honor of continuing in attendance on your Majesty 
if P. von Bergmann is to be permitted to touch your throat again." 



DR. MACKENZIE'S REPORT. 203 

Bergmann's roughness was never forgotten by the Emperor, 
although the nobihty of his nature prevented him from showing any 
resentment, and even from bearing that awkward operator any ill- 
will. That von Bergmann should have been under the impression 
that the Emperor felt grateful to him because Bramanji inserted the 
tube, and that His Majesty should have indicated his satisfaction 
by " a joyful motion of his hand," and by a " thankful shaking of 
our [Bergmann's and Bramann's, to wit] hands," * is indeed re- 
markable, and would tend to show that von Bergmann was not at 
the time in a condition to observe things accurately. The Emperor 
often referred afterward to von Bergmann's roughness, and unim- 
peachable testimony remains as to the opinion of His Majesty on 
this subject in his own handwriting three days before his lamented 
death. I have not been permitted to reproduce this autograph, but 
I shall be happy to show it to anyone who has a legitimate claim to 
inspect it. The means of testing the truth when von Bergmann 
and I make opposite statements may not always be present, but 
here at least is a touchstone of von Bergmann's veracity : von 
Bergmann says that the Kmperor " thankfully shook his hands ; " 
the illustrious patient's own handwriting, on the contrary, shows that 
he was by no means satisfied with his treatment by Bergmann. 

I returned to my room and discussed Bergmann's conduct with 
Mr. Hovell, who, as well as myself, had noticed the strangeness of 
his manner on his arrival. I could not see anything in the case 
which could have justified Prof. Bergmann introducing his finger 
into the wound. It is true that there were some granulations round 
the orifice of the wound, such as are often met with after tracheotomy, 
but there was really nothing whatever to interfere with the passage 
of the canula. Mr. Hovell expressed his surprise to me that von 
Bergmann, who professed to attach such extreme importance to the 
use of antiseptics, should not have at least washed his hands before 
introducing his finger into the tracheal wound. It appears, how- 
ever, according to Bergmann's recent assertion, f that he dexterously 
managed to dip his hand into some carbolized water, without either 
of us being able to perceive it. I had never before seen a canula 
forced into the tissues of the neck, though I had occasionally heard 
of the accident happening to young operators. One case had also 
come under my own notice in which the accident, having occurred 
to a young surgeon, the operation had to be completed by the 
nurse, who, from her large experience in such cases, was easily able 
to introduce the canula into the windpipe. This young surgeon, 
however, was peculiarly unfortunate with his tracheotomy cases, 

* op. cit., p. 81. 
t Op. cit., pp. 81. 



204 



CASE OF EMPEROR FREDERICK III. 



two patients having died under his knife shortly afterward. In all 
these cases, however, the accident had occurred at the time of the 
operation, when there is sometimes a little difficulty in getting the 
tube through the little slit which is made in the windpipe. Under 
such circumstances the mistake, if not excusable, is at any rate 
intelUgible. But in a case where the operation had been done two 
months before ; where the wound in the neck and that in the wind- 
pipe communicated by what may be called a beaten track, along 
which the tube, if properly directed, almost found its own way in, 
it is simply incomprehensible to me that any surgeon should 
have done such mischief unless his wits were disordered through 
nervousness or some other cause. It was like a man trying 
to force a way through the wall of a house when the door stood 
open before him ! The injury inflicted by von Bergmann was no 
doubt much more serious than it would have been had he used a 
right-angled tube, for this instrument is provided with a pilot or 
rounded knob (Fig. 20, C, c), which prevents the sharp edge of the 





Fig. 20. — The extremities of von Bergmann's unprotected, and Durham's guarded, 
canula. B shows the extremity of the canula used by von Bergmann on x\pril 
13, the sharp cutting edge of which is seen at h. C shows the extremity of a 
Durham's canula with the lobster-jointed pilot, which projects at d, d, c, as a 
blunt knob, whAch. prevents the edge of the tube ctttting the te7ider tissues of the 
neck. The pilot is of course withdrawn as soon as the canula is introduced. 

end of the canula from coming in contact with the wail of the tra- 
chea, whilst the ordinary canula as used by von Bergmann was, in 
point of fact, a circular knife (Fig. 20, B, b). It is easy to realize 
what a dangerous weapon this must be in the hands of a clumsy or 
excited surgeon. 

The Reptilia Again. 
The whole of the incident which I have just related was misrep- 
resented in the grossest way by the Kobiische Zeitung. Mr. Hovell 



DR. MACKENZIE' S REPORT. 205 

was accused of having, whilst trying to adjust the canula during the 
night, injured the trachea and pushed fragments of diseased tissue 
into the lungs. This (according to the ingenious scribe) brouglit on 
repeated attacks of suffocation ; and, after several hours' delay, 
Bergmann had fortunately arrived in time to snatch the Emperor 
from the jaws of death by introducing a new tube, with much else 
in the same style. Prof, von Bergmann denies that he caused this 
false and ridiculous statement to appear in the Kolnische Zeitung. 
I shall deal more fully with this subject in criticising that gentle- 
man's published report. (Section II., p. 252.) 

Restdts of Bergmann' s Handiwork. 

On April 13th, the Emperor complained of soreness in the neck. 
He was able, however, to drive into Berlin in a closed carriage with 
the Empress and the Princess Victoria In the evening, as I was 
going out to dinner, I paid a visit to His Majesty at half-past seven. 
I returned at ten o'clock, and at once went to the illustrious patient. 
I found him breathing rather quickly, but there was no hindrance to 
the passage of air through the canula. I left the room to report on 
His Majesty's condition to the Empress, with whom I remained ten 
minutes or a quarter of an hour. When I returned to my sitting- 
room I found that the orderly had called Mr. Hovell to see the 
Emperor. From Mr. Hovell's description I gathered that there was 
no change in His Majesty's condition. 

About eleven o'clock, while Mr. Hovell was still with me, Dr. 
Wegner came to my room and said, " I have been called by the 
orderly. I find the Emperor in a very serious condition ; he is 
breathing very irregularly." I expressed surprise that the orderly 
should have fetched Dr. Wegner from a distant wing of the palace, 
when Mr. Hovell and I had both seen His Majesty within the pre- 
vious half-hour, and I assured Dr. Wegner that there was nothing at 
all serious in the Emperor's condition. His Majesty was a little fever- 
ish, the pulse being 92, and the temperature ioo-8° F., and he was 
breathing rather quickly; but I pointed out to Dr. Wegner that this 
had nothing to do with any obstruction to the passage of air, and 
was merely a nervous phenomenon due to febrile irritation.* As, 
however. Dr. Wegner seemed anxious that I should see the Emperor 
again, I went with him and Mr. Hovell to His Majesty's bedside, 
and watched the august patient for a few minutes. As Dr. Wegner 
said he had no suggestion to make either as regards remedies or 
measures, and did not propose that I should change the tube, I 

* At a later period I came to the conclusion that the quickened respiration which was first noticed 
on this occasion was due to " shock," or in other words to the injury done by von Bergmann on 
the afternoon of the previous day. Before that surgeon had dealt his fatal blow hurried respiration 
had never occurred. 



2o6 CASE OF EMPEROR FREDERICK III. 

concluded diat he was satisfied diat the Emperor's condition was 
not so serious as he had at first supposed. 

Mr. HoveH saw the Emperor several times between eleven and 
two that night. At the latter hour His Majesty wrote on his tablets, 
" Why does the orderly ask if my breathing is difficult ? I do not 
notice anything." At half-past four the Emperor told Mr. Hovell 
that the orderly had again asked him the same question. Toward 
morning His Majesty's breathing became slower and more tranquil, 
though several times during sleep it was very hurried. Fearing lest 
His Majesty should again be worried by the fussiness of the orderly, 
I took steps in the morning to have him replaced by some one better 
fitted for the post. This, like almost everything else which I en- 
deavored to do for the benefit of the illustrious patient, was made a 
ground of attack on me. It was first stated in the Kolnische Zeitung 
that the new attendant was an Englishman. When this was shown 
to be false, it was said that he was a Jew, on no better ground, as 
it proved, than that the man had once been a nurse in a Jewish hos- 
pital ! I mention these things not as of any interest or importance 
in themselves, but as showing the incredibly petty spite which ani- 
mated many of my critics. 

On the 14th the Emperor felt rather poorly in the morning, but was 
up betimes, and did a great deal of writing. In the afternoon he 
drove out, and walked about a little in the Thiergarten. At 6 p. m. the 
Empress sent for me, and said His Majesty had had a slight shiver- 
ing fit. I was quite prepared for the announcement, for ever since 
Bergmann's unfortunate performance on the 12th, 1 had been fear- 
ing the onset of pneumonia (from the trickling of blood and decom- 
posing substances into the lungs), or the development of acute sup- 
purative inflammation round the " false passage." In the evening 
His Majesty's temperature was 103'' Fahrenheit; he had a restless 
night, and on the following morning there were some rales in the 
larger bronchial tubes, though there was no sign of congestion in the 
lungs themselves. Fully realizing the gravity of the situation, I 
requested that Prof. Leyden should be summoned. Finding that 
he was away at Wiesbaden, I obtained permission to call in Prof. 
Senator. That eminent physician, after a most careful examination, 
could detect no disease in the lungs except slight bronchial catarrh. 

The next day (April 16) my worst fears were confirmed. The 
temperature remained at about the same level (102° to 103° Fahren- 
heit), and pus began to be discharged in abundance from the canula 
and from the lower part of the wound. On pressing over the front 
of the neck., and carrying the hand upward, matter could be seen to well 
out more profusely. This proved that an abscess had already formed 
in front of the trachea where the canula had been pushed in by 



DR. MACKENZIE'S REPORT. 



207 



Bergmann. The pus was certain to burrow downward toward the 
chest, and it was only too hkely that nearly the whole of the front 
of the neck would be converted into a huge abscess, involving wide- 
spread disorganization of the structures round about the trachea, 
gradually undermining the Emperor's strength, and leading only too 
surely to hectic, and in no long time to death. This fatal compli- 
cation, be it remembered, was in no way the natural result of the 
disease ; it was attributable solely to the injury done a few days 
before by Bergmann's random stabbing with an unguarded tube. 

On the 17th we had the advantage of Prof. Ley den's counsels; 
he also, after an exhaustive examination, failed to find the least evi- 
dence of disease in the lungs. These organs were again most care- 
fully examined by Prof Senator and Krause, as well as by myself. 




Fig. 21. — Diagram showing the abscess resulting from the " false passage " caused 
by von Bergmann. a, the gullet ; b, the larynx ; d, the false passage ; e, the 
abscess. The diagram 'm half -size, and, of course, only 'i\\-Oyn%\\\Q side view of the 
abscess ; its depth through the neck, i. e. , its lateral extension is not apparent 
in this sketch. 

and we were unanimous in pronouncing them to be quite unaffected. 
Prof, von Bergmann, however, who had not shown himself a master 
of the art of physical exploration of the chest at San Remo (see 
p. 168), insisted, in opposition to us all, that there were secondary 
deposits of cancer in the lungs. He afterward maintained, in spite 



2o8 CASE OF EMPEROR FREDERICK III. 

of the palpable fact that matter could be literally squeezed out of the 
neck, that the pus came from the lungs ! I need not dwell further 
on Bergmann's preposterous opinions on this subject than to point 
out that when, two months later, after the illustrious patient's decease, 
the parts came to be examined, it was clearly proved that no disease 
of the lungs or bronchial tubes had existed, except what developed 
a few days before death. 

Our New Colleagues. 

Shortly after Prof. Ley den's first visit to the Emperor he was ap- 
pointed one of the regular attendants of His Majesty. Prof. Ley- 
den's great clinical experience, and his careful studies in connection 
with alimentation, proved of the utmost importance, and I have no 
hesitation in saying that the extraordinary care and attention with 
which this distinguished physician regulated the nutrition of the 
illustrious invalid considerably prolonged his life. 

Prof. Senator also proved a most valuable colleague. His wide 
therapeutical knowledge and practical experience proved of much 
service in the acute stage of the last attack. In obtaining the co- 
operation of these two eminent physicans, I felt that the great bur- 
den of responsibility, which before that had mainly rested on me, 
was much lightened. 

Extension of the Abscess. 

His Majesty remained in pretty much the same condition for some 
time. His temperature continued to be somewhat high, rarely fall- 
ing below loi" Fahrenheit, and on one or two occasions rising to 
104° Fahrenheit. Remedies were given with the view of reducing 
the fever, but they had little or no effect. His Majesty suffered a 
good deal from hiccough, which often prevented him from sleeping. 
During the day, however, he was still able receive visitors and offi- 
cials, and he expressed a hope that the Queen's contemplated visit 
would not be put off. 

On the 1 8th, as there was again some slight noise during respira- 
tion, Mr,, Hovell removed the small tube which Bramann had intro- 
duced after Bergmann's failure, and put in a larger canula. The 
substitution was effected without the slightest difficulty, and was 
unaccompanied by either coughing or bleeding. There was no 
longer any doubt that an abscess had formed in the place where the 
" false passage " had been made, and that it was extending both 
downward and laterally. On the 20th, a large quantity of pus was 
coughed up during the day. It was not clear whether the abscess 
had burst into the trachea at its lower part, or whether the pus 



DR. MACKENZIE'S REPORT. 



209 




Fig. 22. — The last canula used. Owing to the destruction of the tracheal rings 
caused by Bramann's tube, the right-angled canula did not get enough support 
to hold it in position. 

reached the interior of the trachea only through the surgical 
opening made for the passage of the canula. That a large portion 
of the pus found an entrance to the air-passages in this way was 
evident, but whether this was the only mode of entrance was not 
certain. Whether there was one large abscess or a number of 
smaller ones, von Bergmann having forced the canula in different 
directions in front of the trachea, could not be positively determined. 
On this day I changed the tube in the presence of my colleagues 
for one of the same bore as the Emperor had been wearing before 
the fatal 12 th. 

Some Mernorable Words. 

In view of the serious aspect which the case was assuming, I 
thought it right to inform the Emperor that he was in a position of 
considerable danger, and I ventured to hint to His Majesty that if 
he had any matters to settle, it would be advisable for him to do so 
now. The Emperor received this communication with his usual 
perfect calmness, and shook me warmly but gravely by the hand, 
saying slowly, " I am much obliged to you for telling me. I hope 
I shall get better — for the sake of my people." I noticed that His 
Majesty made a slight pause after the word " better," as if he were 
thinking aloud. At that moment Frederick the Noble was no doubt 
thinking of the enlightened and far-reaching schemes for the inter- 
nal development of Germany, which had been maturing in his 



2IO CASE OF EMPEROR FREDERICK III. 

mind, through all those years of conscientious preparation for his 
great office. The regret for the uselessness of it all was not for 
himself but for his people, who were to lose the blessing of his 
wise and beneficent rule almost before they had learned to 
appreciate it. ■• 

I believe it was on this day (April 20), that the Emperor made 
his touching remark to the Crown Prince : " Lerne zu leiden ohne 
zu klagen.'" (Learn to suffer without complaining.) No one was 
ever better fitted to teach this lesson by his own example than this 
most patient of sufferers. Another story which was current about 
the same lime, to the effect that the Emperor gave to the Court 
Chaplain Schrader a slip of paper bearing these words : " Do not 
pray for my recovery, but for my release," is entirely apocryphal. 
His Majesty was not aware that the distinguished divine had called 
at the Schloss till some hours after he had left. 

Ficreasing Weakness. 

No great change occurred in the Emperor's condition for some 
weeks. My notes chronicle slight oscillations of temperature, 
and trifling differences of appetite, etc., from day to day. Although 
the august patient was able to transact state business, to give audi- 
ences, to receive visitors, and to write his diary, it was impossible 
not to see that he was steadily, though very gradually, losing 
ground. The sudden variations in His Majesty's condition seemed 
to depend largely on whether the discharge of pus was abundant or 
scanty. As long as the abscess emptied itself freely the Emperor 
was comparatively well ; on the other hand, whenever the matter 
was retained for a few hours the feverishness increased, and the 
illustrious patient felt languid and ill. But these slight and tempo- 
rary fluctuations had little effect on the steady decline of health. 
One remarkable feature in the case was the sudden quickening of 
the respiration, which often occurred without any visible cause. The 
Emperor would all at once begin to breathe very rapidly — fifty and 
even sixty times a minute — and after some time the respiration would 
become much slower again. It was noticeable that the pulse was 
not accelerated on these occasions in anything like the same pro- 
portion as the breathing. This proves, as I have already said, that 
the quickening of the respiration was a purely nervous phenomenon. 
The breathing was generally more hurried when the illustrious 
patient was asleep than at any other time, and the sudden diminU'- 
tion of rapidity on his awakening was sometimes very marked. 
Thus, on one occasion I find that there is a drop at the time of 
waking from fifty-three to twenty, and on another from forty-four 
to eighteen respirations in the minute. The Emperor's sleep was, 



DR. MACKENZIE' S REPORT. 211 

as a rule, much broken, lasting only for a couple of hours or so at a 
time. His appetite, as was to be expected from the temperature, 
was indifferent at this time ; but when the fever began to decline a 
little (on April 25), His Majesty took solid nourishment with relish. 
The Emperor received the Queen, who visited Germany at this 
time, on several occasions ; he declared to me, after Her Majesty's 
departure, that he was sure her visit had done him much good. 

How the E.mperor was Nursed. 

This seems to be a convenient place to describe the nursing 
arrangements. His Majesty had a large staff of attendants, but 
with the exception of the orderly, who was on duty in the sick 
room at night, there was no trained nurse among them. The Em- 
peror had four personal attendants, two valets, and two jagers, besides 
his chief personal attendant Wetterhng, who had been his soldier- 
servant almost since the time he joined the army thirty-seven years 
previously. Wetterling gave a general superintendence, adminis- 
tering the medicines and arranging about the food under my direc- 
tions. One of His Majesty's valets had also been with him over 
twenty years, and another for a long period. His two jagers had 
been with him a shorter time — one only a few months — but whether 
they had been a longer or a shorter time in his service, and though 
some were more handy than others, they were all equally devoted 
to their beloved master. The Emperor was indeed a man whose 
soldiers would have shed their last drop of blood for him, and whose 
servants rather than neglect their duty would have fainted at their 
posts. The Empress herself took an active part in the nursing, 
showing a practical knowledge of the art equal to that of any 
trained nurse. Her Majesty had several times given excellent 
proof of her skill and gentleness in dealing with the sick and 
wounded in the military hospitals during the bloody campaigns of 
1866 and 1870 ; and now, when her own gallant soldier husband 
was laid low, she managed the details of the sick room in a way 
that filled us all with admiration. Hitherto the assistance which 
the Empress had given us, though of the greatest value, was more 
of a moral than a practical kind. Often, indeed, when we doctors 
were losing heart, Her Majesty would cheer us up and stimu- 
late us to fresh efforts by her courage and example ; but now her 
struggles were really heroic. Often have I seen her wipe away 
her tears in the Emperor's ante-room, and then go in to him with 
a smihng face, bringing, as it were, a stream of sunshine into the 
chamber of suffering, and chasing the look of pain and weariness 
from the poor patient's countenance. Now Her Majesty took a 



212 CASE OF EMPEROR FREDERICK III. 

more active part in the work, and showed herseh" full of devices 
for ministering to the Emperor's comfort. 

The Question of Opening the Abscess is Considered. 

I several times discussed with Mr. Hovell the propriety of making 
a counter-opening in the neck so as to let out the pus, but as I did 
not know the exact extent of the abscess, or whether there were one 
or more abscesses, and was not certain as to the mode in which the 
pus entered the trachea, I decided against any surgical procedure. 
Several other circumstances also led me to this decision : First, it 
was not at all clear whether, even if an external discharge was estab- 
lished, it would entirely prevent the flow of matter into the trachea, 
and in tlie event of non-success we should have had all the incon- 
venience of an external discharge as well as that which at present 
existed ; secondly, the abscess as a rule emptied itself easily, and 
only occasionally, perhaps once in a week or ten days the orifice 
became obstructed for a few hours ; thirdly, as it was certain that 
the illustrious patient was doomed, it seemed to me that it would be 
a mistake to carry out any operation, however slight. Had the 
abscess occurred in a case of acute disease I should, of course, 
have brought the question of an external incision under the notice 
of my colleagues, but being myself, for the above-stated reasons, 
averse to interference, I thought it better not to raise the point at a 
consultation. 

Presents of Flowers. 

When the Emperor began to recover, quantities of the most 
beautiful flowers were sent day after day from all parts of Germany. 
I have admired the lavish display of beautiful flowers and costly 
exotics in Paris and New York, but the splendid floral oflerings now 
made to the Emperor exceeded anything I have ever seen. Many 
of the bouquets were from private individuals, but not a few of the 
best were sent by the societies of old soldiers which exist in such 
large numbers in Germany, Some came from school children in 
Berlin, and on several occasions violets and primroses were for- 
warded by poor people from England, who expressed their regret 
that their means did not permit them to send valuable flowers. 
These humble gifts gave the Emperor very great pleasure. 

Bergmann Boycotts Me. 

On April 26, on entering my sitting-room to be present at the 
morning consultation, von Bergmann handed me a note in which he 
declined all further intercourse with me except such as was rendered 
necessary by our attendance on the illustrious patient. The sequel 



DR. MACKENZIE'S REPORT. 213 

of his action will be entered into more fully in Section II (p. 251). 
In the meantime I need only state that a day or two later, 
after some further amenities which I had no difficulty in tracing to 
their source, I was obliged to inform the Emperor that Prof, von 
Bergmann had shown fresh signs of hostility to me. I went on to 
say that, under these circumstances, though I did not wish him to 
be relieved of his duties, I thought it was necessary that an eminent 
German surgeon should be called in order to check any misrepre- 
sentation which Bergmann might make in the future. I suggested 
the name of Prof. Bardeleben, who shares with von Bergmann the 
direction of the surgical teaching in the University of Berlin. On 
the following day (April 29), the Empress informed me that she had 
received a letter from Prof, von Bergmann, asking to be relieved 
from further attendance on the Emperor. In the meantime I had 
written to Prof. Bardeleben, who accordingly took part in the con- 
sultation the next morning and remained in attendance till the end. 
Bergmann soon afterward had the bad taste to attack me in a 
communication which he sent to the Berlin Medical Society, because 
I had defended myself against the gross charges made against me 
by his journalistic friends, but he did not attempt to deny that he 
had failed to mtroduce the tube or that he had made a false 
passage. Against these miserable attempts at defamation may 
be set the following telegram which I had the pleasure of 
receiving some days later (May to): "German liberal workmen 
from Charlottenburg and Potsdam, who are making an excursion 
together to-day in the Griinewald, thank you for the loving devotion 
and fidelity which you have exhibited at the bedside of our Kaiser. 
We assure you that your merits will not suffer in the eyes of any 
good and honest German in consequence of the shameless perse- 
cutions {Hetze) directed against you." 

Then follow the names of a number of workmen. 

Further Breakmg-up of the Windpipe. 

Meanwhile the work of destruction was going on in the trachea 
and parts around it. Even then there was no thickening — no 
extension of cancer to the tracheal opening. The breaking down 
of the tracheal cartilages could only be accounted for by the 
injurious pressure on them effected by the large- (14 mm. in 
diameter) mouthed orifice of Bramann's canula. On the night of 
29th-3oth April a flapping noise had been audible in expiration as 
if there were a loose slough at the orifice of the trachea. At seven 
o'clock in the morning the Emperor had a severe fit of coughing 
and brought up a large piece of necrotic tissue. After this the 



214 CASE OF EMPEROR FREDERICK III. 

noise ceased and the breathing became quiet. As the windpipe 
was in such an utterly unhealthy condition, it had occurred to me 
that a tube of lighter material than silver would be likely to do less 
damage. I had therefore ordered a canula to be made of aluminium, 
and this was worn by His Majesty, except on one or two days now 
and then, till the end of his life. 

Temporary Improvement. 

At the beginning of May a considerable improvement took place 
in the Emperor's condition. He felt much better and regained 
strength to a slight extent ; he was more comfortable during the 
day, slept better at night, and took more interest in what was going 
on around him. The vegetations around the tracheal orifice, which 
at the suggestion of Prof. Bardeleben had been treated with bismuth, 
had completely disappeared — a proof that they were not cancerous 
growths as had been positively stated by von Bergmann. The dis- 
charge of pus was still abundant. On May 5, I collected all that 
escaped between 8 a. m. and 8 p. m., and found that it amounted to 
three ounces. As the discharge was generally more copious at 
night than in the day, it follows that an estimate of six ounces 
would be rather under than above the average secretion during the 
twenty-four hours. Such a quantity could not come from a can- 
cerous larynx. Besides, the matter was thick and greenish-yellow 
in color — in fact, laudable pus — very different from the sanious 
putrescent fluid, full of miscellaneous debris, that comes away from 
a cancerous ulcer. In the present instance there could be no ques- 
tion that the source of the discharge was a large abscess-cavity in 
the situation of Bergmann's ''false passage." A further proof of 
the abundance of the discharge is supplied by the number of times 
the canula had to be cleaned in order to prevent its becoming 
stopped up. Thus I find in my notes of this period such entries as 
" canula cleaned eleven times," " seventeen times in the night," 
and so forth. 

On May 12, His Majesty felt some pain in swallowing, which was 
found to be due to aphthous spots on the uvula and pharynx. On 
the 14th, fresh vegetations began to form, and in spite of all treat- 
ment, increased in size, till at the end of a fortnight they had 
coalesced into a single growth about the size of a large date, which 
formed a kind of collar round the whole of the tracheal orifice, ex- 
cept at its upper margin. On June 8, these vegetations began to get 
smaller again, and they gradually shrank, so that at the time of the 
Emperor's death they were no longer visible. 



DR. MACKENZIE'S REPORT. 215 

A Passing Gleam of Simshine. 
On May 16, His Majesty went into the park for the first time for 
a month. The morning temperature on that day was 99*4°, whilst 
in the evening it was 99°. The difficulty of swallowing had almost 
disappeared, and the illustrious patient was making gratifying pro- 
gress. On the 17th, he was in the park again for several hours. He 
sat on a chair for some time and afterward drove in his pony-chaise, 
occasionally walking a few steps. A tent had been erected on the 
lawn and a rug was placed at its entrance. Late in the afternoon 
the pony shied at this rug, and reared so much that he almost fell 
back on the Emperor. Everybody except the illustrious patient 
himself was greatly alarmed. It was only on my pointing out that 
violent shaking might injure his throat that His Majesty consented 
to have the pony taken out of the carriage, which during the rest 
of the evening was drawn by two of the attendants. 

The Emperor's Fo?idness for Music. 

The Emperor spent most of the next day also in the park. He 
drove to the door of the chapel and listened for a long time to the 
choir which was practicing the music to be sung at Prince Henry's 
wedding. I had another opportunity not long afterward of observing 
the Emperor's fondness for music. At Friedrichskron one day in 
the early part of June the choir of the Church of the Twelve Apos- 
tles sang several hymns. His Majesty sat in the next room but one 
to the Muschel Hall in which the choir was, but the doors were 
open and the beautiful voices of the eighty singers constituting the 
choir were very distinct. His Majesty was very much affected by 
the singing; in fact, I noticed that during one of the hymns he could 
not restrain his tears. I procured him a little wine and water, and 
with his usual determination he walked to the entrance of the 
Muschel Hall and bowed his thanks to the singers. 

On May 19, His Majesty drove outside the palace grounds for the 
first time since his recent attack. The people were more enthusiastic 
than ever, and when he came home he felt so well that he insisted 
on remaining in the park for some time. On the 21st, His Majesty 
drove into Berlin again, and on the following day he drove out with 
the Empress. On the 23d, the Princess Irene was expected late in 
the evening, and His Majesty was anxious to sit up to receive her, 
but as I knew that the following day would be a fatiguing one for 
him I persuaded him to retire to rest. 

The Wedding. 

On the 24th, the Emperor, who had had a good night, rose early 
in the morning and spent some time with Prince Henry and his 



2i6 CASE OF EMPEROR FREDERICK III. 

bride. His Majesty went to the Blue Gallery, and was much disap- 
pointed to find that, thinking he would not be able to be present, 
the civil contract had been signed in his absence. He afterward at- 
tended divine service in the chapel. The brisk way in which the 
Emperor rose to his feet was noticed by many of those present, but 
most people thought the illustrious invalid looked much shattered. 
The great effort which he had made to appear as well as possible 
greatly fatigued him, and he could scarcely take any lunch. Late 
in the evenmg, however, he appeared much better, and enjoyed two 
hours in his pony carriage in the park. His temperature at 5 o'clock 
was ioi-i°. It had not been so high as this since May 3. In the 
evening, however, it fell again to 100 -60. 

The Sky again Overcast. 

On the next day the Emperor showed signs of fatigue and 
depression, though he did not complain. From this day (May 
25) I reckoned the commencement of the final decline in His 
Majesty's health. He was never so well after Prince Henry's 
wedding. Some days before that event, however, there were signs 
that the original disease in the larynx was beginning to dissem- 
inate itself in adjacent parts. On May 20, a round nodule about 
half a centimetre in diameter, was noticed under the skin about an 
inch above the inner end of the right collar-bone. It was movable 
and moderately hard, and the skin over it was of natural color and 
appearance. This nodule gradually increased in size, and in the 
early part of June its surface became slightly inflamed. It was 
judged to be a secondary point of malignant infection, and as a 
matter of fact it was found on examination after death to contain 
some cancerous elements. 

On May 26, the Prince of Wales accompanied the Emperor in a 
drive through the Thiergarten to the Belle Vue, where he too took 
leave of His Majesty for the last time. On the following day the 
Emperor showed signs of fatigue and drowsiness, and seemed once 
more to be gradually losing the energy he had lately regained. On 
the 29th, however, he was roused by an incident quite outside the 
ordinary run of his life for a long time past. His Majesty inspected 
three regiments of Guards, which marched past under the command 
of the Crown Prince. The Emperor, who was wearing his helmet 
for the first time since his accession, sat in his victoria. He was 
greatly moved. Whether from the weight of his helmet or from ex- 
citement, the Emperor's head was bathed in perspiration, although 
the day was not at all hot. Immediately after the inspection I got 
him some wine, which seemed to revive him. I said to His Majesty, 
" I am afraid, sir, it was rather tiring for you seeing the troops 



DR. MACKENZIE'S REPORT. 217 

march past." He replied, " No, but it is the first time I have seen 
my soldiers." The Emperor seemed thoughtful for the rest of the 
day, and indeed, under the circumstances, there was sufficient mat- 
ter for sad reflec tions. This inspection certainly seemed to try the 
Emperor more than anything which had occurred for some time. 

Visit to the Mausoleum. 

On May 31, the Emperor, who had driven into Berlin the day 
before, was fairly comfortable. In the evening His Majesty asked 
me if he might pay a visit the next day, before leaving Charlotten- 
burg, to the mausoleum ; thinking, however, that the day would be 
a fatiguing one, I suggested his going that evening. We silently 
wended our way to the little chapel, and the Emperor slowly mounted 
the steps attended by one of his faithful jagers. I remained outside, 
and, whilst waiting, my thoughts naturally turned to the Emperor 
William, and it was a source of satisfaction to me to remember that 
he had expressed himself as entirely satisfied with my treatment of 
his beloved son. Of this I had received the assurance both from 
Prince RadoHn and General Eoe. The latter gentleman told me in 
San Remo in the previous autumn that the deceased monarch, in 
the presence of several senior officers, had expressed his complete 
approval of what I had done ; and the Hof-Marshal gave me similar 
testimony — in this case, I believe, by the express desire of the Em- 
peror William. 

In a short time His Majesty descended the steps of the mauso- 
leum, looking sad and weary. Shortly afterward he said to me : *' I 
shall go to bed early to-night. I feel tired." 



CHAPTER XXII. 



THE emperor's LAST STAY AT POTSDAM. 



It had been arranged that on June i the Emperor should be 
removed to Potsdam, which from long residence there he looked 
upon as his natural home. Before starting, however, there was a 
little difificulty with the canula, and as the incident was an almost 
exact replica of the unfortunate episode of April 12, with the part 
of Bergmann left out, it may be worth while to relate it. I had 
changed the tube in the morning for a shorter one in the presence 
of all my colleagues. Half an hour after their departure the 
Emperor's breathing became slightly tracheal. I at once changed 
the inner tube, but in five minutes His Majesty sent for me again, 
when I found that there was a slight noise on inspiration. As we 
were leaving for Potsdam in a few minutes there was no time to 
send for Bardeleben, and as I thought it would be unadvisable to 
allow the illustrious patient to travel with the new tube in his throat, 
I replaced the one he had formerly been wearing. 

Now I might have easily magnified this little incident, and repre- 
sented myself as having rescued the Emperor from impending 
suffocation. The circumstances were almost exactly similar to those 
of the fatal occasion on which Bergmann had done such mischief. 
In neither case were there any symptoms of the least urgency; 
there was only a trifling degree of dyspnoea, and the breathing was 
accompanied by a slight sound. 

The Emperor's Last Joiirtiey. 

The Emperor drove through the grounds in his pony-chaise to 
the banks of the Spree, which on one side forms the boundary of the 
Charlottenburg park, and embarked on board the yacht Alexandra, 
which was to take him to Potsdam. Thousands of people had 
assembled on the opposite side of the river, and when His Majesty 
appeared their enthusiasm knew no bounds; a strong body of 
mounted police had been stationed to prevent the crowd approach- 
ing too near the river, but in the excitement of the moment the 
people pressed forward to the very brink of the stream, and it was 
very fortunate that some were not precipitated into it. When the 
little yacht steamed off, a large part of the crowd ran by the side of 
the river. On reaching Spandau, which was gaily decorated, 



DR. MACKENZIE' S REPORT. 



219 



thousands of school children were seen to be assembled on the 
banks to greet their sovereign, and on passing under the bridge, 
flowers came down in such a deluge that it took two of the sailors 
half an hour to gather them up. VVe arrived at Gleinicke bridge at 
about one o'clock, and found a number of carriages which conveyed 
us to Friedrichskron. The Emperor was very little fatigued, ate a 
good luncheon, slept for a few hours, and then took a drive in his 
pony-chaise in the park. 

Fresh Complications. 

For the next three or four days there was no change in His 
Majesty's condition. He slept fairly well (for him), and was able to 
go out a good deal when the weather permitted. He was, however, 
more easily fatigued than he had hitherto been, and it was only too 
clear that his life was ebbing away sensim sine sensu. On June 6, 
the temperature, which for some time previously had averaged from 
99" to ioqo F., rose to 102 '4° F., and there was a great deal of 
coughing, owing to the quantity of matter which found its way into 
the windpipe. That night he hardly slept at all, and the next 
morning he was very weak. He insisted, however, on getting up 
about 11.30, and giving audience to General Albedyll. 

On the evening of the same day (June 7) it was noticed by the 
attendant that whilst the Emperor was drinking some milk a small 
quantity of the liquid came out through the canula. During the 
night the same thing was repeatedly observed by Prof. Krause, who 
had taken the night duty since the 4th, as Mr. Hovell had been 
obliged to return to England on account of the sudden death of 
his father. At 6.30 on the morning of the 8th, Krause came to my 
room and said, "What you have so often feared has now hap- 
pened ; a fistula has formed between the larynx and the oesophagus." 
He then told me what he had witnessed during the night, adding 
that once or twice nearly the whole of the milk which the Emperor 
had taken into his mouth had run out through the tube. At the 
morning consultation, in which, besides Prof, Krause, Dr. Wegner 
and myself, Profs. I>eyden, Senator and Bardeleben took part, 
I remarked that although the symptoms seemed to point to the 
existence of a laryngeal fistula, I was nevertheless not at all sure 
that the passage of liquids into the larynx was not merely the result 
of the imperfect action of the epiglottis. I expressed the same view 
to my colleagues on several occasions subsequently. The argu- 
ment in favor of this theory was the rapidity with which liquid 
food escaped from the pharynx into the larynx, and thus through 
the tracheal opening, whilst on the other hand the idea that there 
might be a laryngeal fistula was supported by the fact that occasion- 



CASE OF EMPEROR FREDERICK III. 



ally His Majesty was able to swallow without any liquid passing 
into the larynx, a circumstance tending to show that the fistulous 
passage occasionally became closed. 

The complication in any case was a most serious one, for in the 
weak condition of the Emperor anything which interfered with his 
taking a sufficient amount of nourishment would certainly bring his 
life very speedily to a close. At this time he was still able to take 
a fair quantity, as the following diet-sheet (for June 8) will show: 
lo A. M.j about half a plateful of very thick porridge; i p. m., four 
eggs beaten up in wine; dinner, some puree of chicken, with a little 
mashed potato; in the afternoon a large piece of cream ice and 
three eggs; no supper, but at lo p. M. a large plateful of shaped 
boiled rice. In the night some rice, cocoa, and eggs. 

With the view of preventing the fluids which were swallowed 
from trickling down the windpipe, it was determined to use a tam- 
pon-canula. This accordingly I put in on the 9th in the presence 
of Profs. Bardeleben, Leyden, Krause, and Dr. von Wegner. His 
Majesty slept better the next night than he had done for some 
little time ; he was able to take eight eggs in the course of it, and 
said in the morning that he felt better. 

Ho Progress. 

Seeing that the Emperor was sinking day by day, I thought it 
my duty on the morning of June 10 to inform him that he was not 
doing well. I said to him: "I am sorry to tell you, sir, that you 
are not making progress." His Majesty replied, "I feel pretty 
well to-day." Nothing more was said, but some hours afterward 
the Emperor handed me a slip of paper, on which he had written — 




^fiJ\/\^ 



DR. MACKENZIE'S REPORT. 221 

These pathetic words* showed me that the dying monarch had 
fully understood the meaning of what I had said to him. 

On the following morning (June 11), as the breathing had become 
somewhat tracheal, I introduced a longer tampon-canula. As, how- 
ever, air did not come quite freely through the tube, I removed it, 
and then passed it in again with the greatest ease. In doing so, I 
felt that, about two or two and a half inches below the tracheal 
opening, there was a slight projection forward of the posterior wall 
of the trachea, and by directing the lower end of the canula forward, 
and fixing the instrument in that position, I overcame the slight ob- 
struction and the breathing became quiet. The discharge of pus 
had now become much less profuse, but the tube still required to be 
cleaned pretty frequently. During the day a good deal of fluid was 
seen to escape by the side of the canula after swallowing ; the sub- 
glottic region was therefore tightly plugged with five small pieces of 
sponge, which partly checked the leakage through the wound. 

Dying in Harness. 

Even at this time the Emperor battled with the prostration which 
was at last beginning to paralyze his hitherto indomitable energy. 
On this very day (June 11), he was writing his diary and signing 
documents nearly all the morning, and the amount of work which 
he got through was wonderful under the circumstances. I always 
noticed that when His Majesty felt worse than usual, he worked 
harder than ever ; he had an almost overwhelming sense of the 
duties of his position, and seemed resolved almost literally to die at 
his post. I never discouraged the illnstrious patient from working, 
as I knew that the disappointment he would have felt at being com- 
pelled to be idle, would have more than counterbalanced any good 
he might otherwise have derived from remaining quiet. Moreover 
the work itself seemed actually to sustain him, and it no doubt was 
useful in diverting his thoughts from his own condition. 

Artificial Feeding. 

On June 12, Mr. Hovell, who had returned from England the 
day before, informed me that the Emperor had been able to take 
very httle food during the night, and that a great part of what he 
did take escaped at the side of the canula. At the consultation 
afterward, it was unanimously agreed that artificial feeding had be- 
come necessary, and I was requested to undertake it. I pointed out 
to my colleagues that, owing to the relaxed condition of the pos- 

* I am not sure whether the word have is omitted before "made," or whether His Majesty- 
meant to write ?«a^^ instead of made ; the former expression would be a Hteral translation of the 
German phrase. 



222 CASE OF EMPEROR FREDERICK III. 

terior wall of the trachea caused by the exfoliation of the cartilages 
in the upper part of the trachea, and to the probably softened state 
of the oesophageal walls, the passage of a feeding-tube would be at- 
tended with considerable danger, but it was decided that the opera- 
tion was imperatively indicated, whatever the risk might be. 
Accordingly at about 1 1 o'clock that morning, I passed an oesopha- 
geal tube, and introduced about a quart of milk through it. His 
Majesty was again fed in the same way at 2 p. m., half a litre of con- 
densed milk with some cream and whisky being given on this occa- 
sion. During the day I took an opportunity of pointing out to His 
Majesty that he was now almost entirely dependent on the feeding- 
tube for his supply of nourishment, and that therefore if any diffi- 
culty should arise interfering with the passage of the tube, he would 
be reduced to a condition of the most imminent danger. The Em- 
peror merely bowed affirmatively on hearing this statement, but 
asked no questions. In the evening the Emperor wished to go out for 
a drive, but I thought it better for him to remain on the balcony. At 
II o'clock he was again fed. In the middle of the day the breathing 
became tracheal, and the supply of air diminished. This difhculty 
gradually increased in the evening, and though Prof, Bardeleben 
was expected, the breathing became so bad that 1 thought it desirable 
to endeavor to alter the position of the tube. After inserting the pilot, 
I tilted its point forward, and in this way succeeded in disengaging 
the lower end from a fold of the mucous membrane covering the 
posterior wall of the trachea which partially blocked up the lower 01 i- 
fice. The breathing at once became easy. I retired to rest at 
3 A. M., leaving Mr. Hovell on duty. There had been scarcely any 
discharge of pus for several days; but on this day (June 12) some 
very offensive matter escaped. From this time there was hardly 
any secretion of pus, but a good deal of mucus continued to come 
through the canula. 

On the 1 2th, the Emperor was fed with the tube three or four 
times during the day. In the course of the morning I saw the ser- 
vants making extra preparations on the balcony, and was told that 
this was because the King of Sweden was expected very soon. I 
had thought that the King's visit had been put off on account of 
the Emperor's condition ; but it was now too late to intercept the 
carriages. Besides this, I knew that nothing could now make any 
difference to the august sufferer. His Majesty was rather breath- 
less, but he was able to receive the King; the interview lasted only 
a few minutes. Before he left Friedrichskron I had the honor to 
be presented to King Oscar, who asked me what I thought of the 
Emperor. I replied, " It is scarcely necessary to point out to you, 
sir, that the Emperor is in a most critical condition, from which I 



DR. MACKENZIE' S REPORT. 223 

think it is almost impossible for him to rally ; should he, however, 
get over this attack, his life might be spared for a few weeks."* 

The Beginning of the End. 

At 3 A. M., on this day (June 13) I noticed a change in the Em- 
peror's condition, which showed that the end was approaching. 
There were signs that inflammation of the lungs had evidently set 
in, and I knew that His Majesty's sufferings would soon cease. I 
had promised to inform the Empress at once if any change 
occurred, and accordingly at 4 o'clock I knocked gently at her bed- 
room door. She was not asleep, and answered me immediately. 
As soon as possible the Empress was by the side of her dying hus- 
band, and from that hour she never left his bedside for more than a 
few minutes at a time. The Emperor remained surrounded by the 
members of his family throughout the day. As he was very rest- 
less, and had not slept during the night, I gave him a mild sedative 
draught. Soon afterward he fell asleep and slumbered till 6.30, 
when he said he felt hungry, and asked me to feed him. I admin- 
istered a quart of milk with a little whisky through the tube. He 
received nourishment in this manner twice again during the day. 
He showed very little interest in general matters, but was very par- 
ticular to have his tube changed directly there was the least sound 
in breathing. 

Thoughtfid for Others to the Last. 

I have said more than once that the Emperor was the most con- 
siderate of men, and I cannot forbear relating a striking instance of 
this quality which occurred within a few hours of his death. My 
sitting-room was close to His Majesty's room, but in order to reach 
the latter I had to pass through three rooms. In order to get to his 
bedside more quickly I generally used to go along an outside bal- 
cony so that I had only the ante-room to pass through. Just 
before daybreak on the morning of June 15 it was dull and chilly. 
In consequence, I suppose, of exposure to the air in going by the 
balcony I became a little asthmatic. Whilst I was changing his 
canula on two or three occasions during the night, the Emperor put 
his hand lightly on my chest and looked up at me with a glance of 
earnest sympathy, thus mutely expressing his regret that I too was 
suffering. Those who have much to do with the sick know well 
how prolonged illness often breaks down the natural framework of 
the character, making even those who in health were utterly unsel- 
fish come to be regardless of anything but their own suffering. 

* I should not have thought it necessary to repeat the subject of this interview had not the 
"reptile" press recently (Septeniber) recommenced on its old system of misrepresentation, and 
printed a most false and entirely ridiculous account of my interview with the King of Sweden. 



224 CASE OF EMPEROR FREDERICK III. 

Frederick the Noble in this, as in everything else, rose above the 
ordinary standard of humanity; even in the agony of death he re- 
mained true to his own generous nature. 

Last Scene of All. 

At 4 o'clock I called Mr, Hovell, and at 5 I tried to snatch a few- 
minutes of rest in an armchair. An hour later, however, the Em- 
peror complained of a feeling of sinking, and signified his wish that 
that I should give him some nourishment. After this he seemed to 
be somewhat better for an hour or so, and a little later he passed 
into a deep sleep, which was, however, broken from time to time 
by the irritation in his throat. 

In order not to intrude on the grief of the sorrowing family, at 
10 o'clock I took up my post in the room immediately adjoining the 
Emperor's bedroom, paying a short visit to the Emperor every few 
minutes. At 11 o'clock the eyes of the poor patient, which had 
languidly followed every movement of the Empress, became fixed, 
the intervals in drawing breath became greatly lengthened, and soon 
after 1 1 A. M. I had the sorrowful duty of announcing to the Em- 
press that life was extinct. With his broken-hearted family, and 
several of his devoted servants kneeling round him, Frederick the 
Noble breathed his last. 

Thus passed away the noblest specimen of humanity it has ever 
been my privilege to know. Of his military achievements and his 
political wisdom it would be presumption for me to speak. During 
his life his natural reserve and the circumstances in which he was 
placed led him to efface himself to a great extent, so far as the prac- 
tical conduct of affairs was concerned. He could not, however, 
conceal his kindness of heart, which thus came to be the leading 
feature in the public estimate of him. Only those whose official 
position brought them into personal contact with him, and a chosen 
few who were permitted to enjoy his confidence, knew that Fred- 
erick the Third was a man of commanding intellect. His courage 
in the field is known to all the world ; his compassion for suffering 
and misfortune, and his chivalrous forbearance toward the weak are 
acknowledged most freely by those whom he conquered in war. It 
was my lot to know him under very different circumstances ; to see 
him face disease and suffering with the same unostentatious heioism 
as he had confronted the enemy in the battle-field ; to see him 
whilst standing in the very shadow of death, still eager to do what 
he could for the people over whom he ruled. Only those who had 
the privilege of constant intercourse with the Emperor Frederick 
know how much poorer the world is for his death. No one could 
know him even slightly without loving him ; no one could be more 



DR. MACKENZIE'S REPORT. 225 

intimately acquainted with him without reverencing him as one of 
the most large-minded and noble-hearted of men. Though naturally 
somewhat reserved and dignified, he loved to talk freely with all 
classes of people. One thing which particularly struck me in him 
was the absolute genuineness, the transparent honesty of the man. 
He never affected a knowledge which he did not possess, but was 
modestly deferential to those whom he thought better informed than 
himself. Though active when the necessity for action arose, his na- 
ture was contemplative, and his mind essentially judicial. The man- 
liest of men, he had the gentleness and purity of soul of the purest 
of women. He has gone down to his grave leaving us the memory 
and example of a stainless life and a beautiful death. 



CHAPTER XXIII. 



THE EPILOGUE. 



A Trap is Laid for Me. 

After the Emperor's death, having had no rest for nearly 60 hours, 
I threw myself on my bed about 2 p. M. ; but I was shortly after- 
ward awakened by one of the adjutants, who informed me that 
the Emperor and Prince von Bismarck desired to see me. I quickly 
arose and accompanied this gentleman to the young monarch, 
whom I found sitting with the Chancellor in what had previously 
been the adjutant's room. His Majesty* received me courteously, 
and said that Prince Bismarck would like to speak a few minutes in 
conference with me. The Chancellor thereupon invited me to 
retire with him into an inner room, where he suggested that I should 
draw up a brief report on the case of the Emperor Frederick. I at 
once expressed my readiness to do so. The Chancellor then said, 
" Will you do so before you leave ? " I replied, " WiUingly, your 
Highness. I shall leave on Monday, and I will certainly draw u^) 
the document you ask for before then." 

After this conversation I was extremely surprised the next day 
when an official from the Haus-Ministerium called on me at one 
o'clock and asked for my report. I told him 1 had not had time to 
draw it up. He said, " If you will dictate it to me I shall be happy to 
take it down ; " but I pointed out that such an important document 
could not be dashed off in that way. The official then remarked 
that it was most important it should be prepared immediately, as 
the ministers were waiting for it. I then said, " In that case I will 
write it for you," and it was arranged that he should wait in the 
palace for the document. Within half an hour I drew up a report 
to the following effect: 

" ScHLOss Friedrichskron, June 16, 1888. 

"It is my opinion that the disease from which the Emperor Friedrich III. 
died was cancer. The morbid process probably commenced in the deeper tissues, 

* Among the thousand-and-one incorrect statements which appeared in the papers, there was one 
to the effect that I had asked for an audience of the new Emperor, who had refused to see me. I 
think it right to state here that I never sought for an interview of any kind with His Majesty. 



DR. MACKENZIE'S REPORT. 227 

and the cartilaginous structure of the larynx became affected at a very early date. 
A small growth which was present when I first examined the late Emperor was 
removed by me by several endolaryngeal operations, and though all the portions 
taken away were submitted to Prof. Virchow, he was unable to detect in them 
any evidence of the existence of cancer. Examinations of the sputa made at 
the beginning of March by Prof. Waldeyer, however, led that pathologist to 
believe'^that cancer was then present. Whether the disease was originally can- 
cerous or assumed a malignant character some months after its first appearance, 
it is impossible to state. The fact that perichondritis and caries of the cartilages 
played an active part in the development of the disease no doubt largely con- 
tributed to make it impossible to form a decided opinion as to its nature till 
quite recently. 

" MoRELL Mackenzie." 

" In so far as my observations since last August permit me to form an opinion, 
I concur entirely with Sir Morell Mackenzie's views. 

"T. Mark Hovell." 

When I proceeded to find the official, I was surprised to dis- 
cover him in earnest conference with Prof, von Bergmann. I 
handed him the report and withdrew. Half an hour later, Dr. von 
Wegner looked in on me in my sitting-room and said, '■'■ K post-mor- 
tem examination is going to be made. Do you care to come ? " 
I answered, " Do I care to come ? How can you ask such a ques- 
tion ? " I immediately called Mr. Hovell and went with him to the 
room where the autopsy was going to be performed. 

Miscarriage of the Plot. 

I now saw why such extraordinary pressure had been brought to 
bear on me to make me send in my report on the case at once. It was 
hoped that being under the absolute conviction that there was to be 
no post-mortem examination, I should be entrapped into making some 
equivocal statement as to the nature of the disease. After I had 
thus committed myself, the autopsy would be made and the exist- 
ence of the cancer clearly proved to my everlasting discomfiture. 
It was a neat enough little plot in its way, but its authors had left 
two rather important matters out of account which made their 
amiable intention fail of its effect. In the first place, since Wal- 
deyer had told me of the result of his microscopic examination I 
had frankly accepted the cancer diagnosis as definitively established. 
It was not at all likely therefore that I would now stultify myself by 
quibbling about the matter. In the second place, although it 
appeared to be taken for granted, quite gratuitously, that I did not 
wish .for an autopsy to be made, I had, in fact, myself proposed it. 
A few hours before the Emperor's death, I had ventured to point 
out to the Empress that it was desirable that at least a partial post- 
mortem examination should be made, in order to ascertain the exact 



2 28 CASE OF EMPEROR FREDERICK III. 

situation and extent of the disease. Her Mujesty was very unwill- 
ing to consent to this ; but at last promised that she would allow 
whatever I thought necessary to be done. When the Emperor 
had breathed his last, however, Her Majesty, in the first outburst 
of her grief, which up to that moment she had heroically kept in 
check, turned to Dr. von Wegner and begged him to promise that 
her beloved husband's body should not be touched. The Emperor 
William II. expressed his concurrence with his mother's wishes as 
to this matter, and gave oiders that they should be respected. On 
the following morning, however, strong representations were made 
to His Majesty by General von Winterfeld and others, at the insti- 
gation of Prof, von Bergmann, that as the Prussian law required 
that the cause of death should be constatirt, it was necessary that a 
post-mortem should be made for that purpose. As far as the legal 
aspects of the case were concerned this was mere sophistry. The 
cause of death had already been certified {constatirt) by myself, and 
von Bergmann or any of the other doctors could have also given 
a certifica,te, if it had been thought desirable. The Emperor 
William II., however, not perceiving the real motive of the great 
desire for a post-mortem examination, yielded out of scrupulous 
regard for the law. I have no doubt that Prof, von Bergmann was 
sorely disappointed at the collapse of his little scheme. 

Report of Post-Mortem Examination. 

The post mortem examination was made by Prof. Virchow in the 
presence of Prof. Waldeyer, who, during the investigation carried 
out by Virchow, cursorily examined some of the parts removed 
from the body. There were also present Drs. von Wegner, Bar- 
deleben, Eeuthold, von Bergmann, Bramann, Mr. Hovell and 
myself. Profs. Leyden, Senator, and KrAuse, who had attended 
the Emperor up to the day of his death, were not invited, and, as 
already stated, I was only told of the post-mortem just before it was 
made. 

Although the autopsy was carried out with care, it was necessa- 
rily very incomplete, and unfortunately somewhat hurried by Count 
Stolberg-Wernigerode, who several times reminded us that it was 
necessary to finish the examination as soon as possible, as it had 
been arranged that the lying-in-state should take place within an 
hour of the commencement of the autopsy. 

The (tracheotomy) wound and an incision over the right carotid 
artery (made for the purpose of injection) had been stitched up, 
the cavity in the front of the neck having been previously packed 
with cotton-wool and bismuth. On removing the stitches " from 



DR. MACKENZIE'S REPORT. 229 

the stitched-up linear wound 6| cm. long," after the removal of the 
large quantity of cotton-wool and bismuth, the report says: '■'■A 
cavity is left, measuring 5 cm. in depth and almost as much hi lefigth, 
the opening of which, after removal of stitches, gapes to the exte7it of 
2\ cm.''' An incision was made through a nodule situated in the 
skin, and partly in the subcutaneous tissue on the right side of the 
neck a little below and external to the tracheotomy wound. The 
larynx, as well as the upper portion of the trachea and oesophagus, 
were ligatured and removed. Nearly the whole of the larynx was 
destroyed, its place being occupied by a large, flat gangrenous 
ulcer ; the epiglottis and ary-epiglottic folds alone remained. At 
the base of the epiglottis, on the left side, was a nodule as large as 
a cherry, and near it were several similar nodules of various sizes, 
but all much smaller than the first one. The mucous membrane of 
the trachea immediately below the (tracheotomy) wound was free 
from ulceration and scars. The lower part of the trachea and its 
bifurcation were not examined. The lungs appeared outwardly 
quite healthy " and everywhere full of air, down to the lowest edge 
of the lower lobe," but there was some hypostatic congestion, and 
there were a number of minute collapsed patches in the bases con- 
taining dilated bronchial tubes, partly surrounding which were layers 
of extravasated blood. On section, a large number of foci were 
found in the interior of the lower lobes, some of which contained a 
material resembling pus, whilst in others the whole mass was still 
solid. Scattered throughout the upper lobes of both lungs were 
found similar very pale foci, in which a large number of yellowish 
nodules were closely packed together. On opening' up the oeso- 
phagus behind the cricoid cartilage, there was found a collection of 
greyish-brown secretion, and on removing this there was no trace 
of perforation. On the left side of the neck, close to the jugular 
vein, was a lymphatic gland about as large as a pigeon's egg, which 
in its interior showed a medullary-looking yellow spot. On slitting 
up the bronchial tubes they were found dilated throughout with 
thickened walls, the mucous membrane lay in thickened folds, and 
was covered with discolored debris. 

Owing partly to the fact that the cavity in the tissues in the front 
of the neck had been filled up with cotton-wool and bismuth, and 
partly to the circumstance that the purulent secretion had ceased 
during the last three or four days of the Emperor's life, there was 
nothing to call special attention to the existence of the abscess, the 
general situation of which Mr. Hovel! and I were easily able to 
identify. 

In consequence of the lower part of the trachea not having been 
examined, the question as to how the pus during life reached the 



230 CASE OF EMPEROR FREDERICK III. 

interior of the trachea, viz., whether by merely welHng upward, 
and entering by the (tracheotomy) wound, or by passing through 
one or more fistulous tracks between the tracheal rings, was unfor- 
tunately not determined. 

Profs. Virchow and Waldeyer subsequently made a microscopical 
examination of particular sections taken from the body of the late 
Emperor, and the following is an epitome of their report. The 
nodule at the base of the epiglottis contained an alveolar structure 
with epidermoidal contents, among which were nest-cells. The 
cutaneous nodule removed from the neck also contained nest-cells. 
The lymphatic gland, however, showed the highest degree of change, 
the normal structure being " replaced by a loose alveolar tissue, the 
spaces of which are closely filled with epidermoidal cells having 
large nuclei." In the foci in the lungs were found thick clusters of 
pus cells, but no cancer cells. 

Afiother Calunmy Refuted. 

One other point I must touch on before bringing this narrative to 
a close. Among the many false charges which have been brought 
against me in connection with this case, there is one which for ob- 
vious reasons I could not take any notice of while the Emperor 
was still alive. It was said that I deliberately deceived him as to 
his condition, and buoyed him up with false hopes, leading him to 
believe that he would recover. Now, as to the first point, I will 
frankly say at once that I did not ever say bluntly to the Emperor, 
" You are suffering from cancer, sir; you are a doomed man." I 
did not do so 'in the earlier stages of his malady, because the nature 
of the case appeared to me to be doubtful, and it is a cardinal rule 
of medical practice not to communicate suspicions of that kind to 
the patient, even if they seem well-founded. At a later period, 
when the case had assumed a more serious aspect, my readers will 
recollect that I was perfectly open with the illustrious patient, who 
thanked me for being so frank with him. (See p. 141.) Prof, von 
Schrotter afterward made a formal communication to the Crown 
Prince, on behalf of us all, in which he clearly conveyed what was 
thought to be the nature of the disease. 

What the Emperor's own inmost thoughts were as to his condition 
and prospects I am quite unable to say. For a very long time 
before his death, he asked no questions except as to what I may 
call the non-essential features of his case, such as the pulse, the 
temperature, etc. Though fond of conversation, and a most delight- 
ful companion, he was always extremely reserved about himself. 
Though I was thrown into such intimate contact with him for so 
long a time, I know less about the real state of his mind with regard 



DR. MACKENZIE'S REPORT. 231 

to his own case than I do about almost any other patient whom I 
have had under my care. It may be that he hoped against hope, 
but he never spoke either of his hopes or fears to me. 

It must be remembered too that the Emperor had had far greater 
opportunities of hearing the truth — or what was supposed to be the 
truth — about his condition than fall to the lot of ordinary patients. 
Soon after the commencement of his illness Gerhardt's opinion as to 
its nature had reached his ears. , He was a man of heroic fortitude, 
and not at all likely to brood over fancies, but so terrible a sugges- 
tion must necessarily have left a lasting impression on his mind. 
Such an idea cannot be thrown off by an effort of will; hceret lateri 
faialis hiriido. The Prince's own question to me when I mentioned 
the unfavorable change which had taken place (p. 141), shows that 
the notion of cancer was always present to him. He was in no 
way misled by me as to the nature of his complaint. I told him 
honestly, exactly what I thought when the occasion arose, and I 
treated him precisely as I should wish to be treated myself under 
similar circumstances. 

Consoling Reflections. 

In looking back on this sad case there are one or two matters 
which will always be a source of deep satisfaction to me : One is 
that through the mild and painless operations performed by myself 
the dangerous methods recommended by Gerhardt and von Berg- 
mann were prevented, and that I thereby not only prolonged the 
life of the Emperor, but also saved him much suffering. The other 
point which affords me some consolation is that I was able to pre- 
vent His Majesty suffering any actual pain during the long course 
of his distressing complaint. Even in February, when he was put 
to so much trouble and inconvenience, when he passed weary days 
and sleepless nights, whilst von Bergmann and Bramann were in 
charge of the case after the performance of tracheotomy, the 
Emperor experienced no actual pain. Except at the moment when 
von Bergmann made the "false passage" and forced his finger into 
the wound, I do not think he ever had a moment of severe pain. 
Occasional slight neuralgia in the head and mild muscular rheuma- 
tism were his worst troubles in this respect. 



SECTION II -CONTROVERSIAL 



CHAPTER XXIV. 



THE TRUTH ABOUT THE PROPOSED OPERATION. 



Theses Stated. 
I propose to show in the first part of this section — 

{a) That the operation of thyrotomy ( Laryngofissur), which it 
is stated it was proposed to perform on the Crown Prince in 
May, 1887, is not free from risk as is pretended by von Berg- 
mann, but, on the contrary, is a dangerous procedure, soon 
leading to death. 

ip) That the proposed operation does not aflbrd a fair prospect 

of eradicating a mahgnant growth, but, on the contrary, is 

most frequently followed by recurrence. 
{c) That the presence of cancer was not ascertained even with 

approximate certainty until November, 1887, if indeed it 

really existed before that date.* 

In the second part I shall briefly consider some of the individual 
reports contained in the pamphlet entitled, Die Krankheit Kaiser 
Friedrich desDritten. (" The Illness of the Emperor Frederick III.") 

PART I. 

I shall now proceed to prove my first proposition {a). That the 
operatio7i of thyrotomy [Lafyngojissur), which it is stated it was pro- 
posed to perform on the Croivn Priiice in May, 1887, is not free from 
risk as is prete7ided by von Bergmann, but^ on the contrary, is a 
dangerous procedure, soon leading to death. 

The Danger of the Operation. 

Prof, von Bergmann maintains that the operation which he was 
about to perform is free from danger, and he states that he has 

* It must not be forgotten that even in November the microscopic evidence was still vi'anting, and 
that it was not till February, 1888, that the presence of cancer was conclusively proved. 



DR. MACKENZIE'S REPORT. 233 

performed it seven* times successfully. He does not, however, 
give any details of these operations, nor does he even say that they 
were done for cancer. Vague statements of this kind are of no 
value whatever, nor are they accepted by compilers of surgical 
statistics. 

Prof, von Bergmann further states! that there appeared in the 
Centralblati fiir Laryngologie, since its publication four years ago, 
reports of fifteen cases of thyrotomy (^Laryngojissur), only one of 
which had proved fatal, and that in this instance death was due to 
diphtheria. Such a statement as this is in the highest degree mis- 
leading. Anybody not already aware of Prof, von Bergmann's 
reckless method of making statements which have but slight founda- 
tion in fact, on reading this sentence would suppose that all these 
fifteen patients had recovered from cancer by means of the opera- 
tion, except one. It will scarcely be believed that the truth is 
almost exactly the reverse. Such a number of inaccuracies are 
contained in von Bergmann's statement that they require to be set 
forth in detail. The operation was actually reported in the 
Centralblati no less than thirty times ! The disease, however, was 
cancer only in ten cases. Of these ten cases only five patients 
survived the immediate effects of the operation, and only one 
patient (Billroth's) remained free from the disease for over two 
years. In the twenty other cases in which the operation was per- 
formed for non-malignant disease, thirteen were papillomata, the 
large majority of the patients being children from two to eight years 
old. There was one case of polypus, one of oedema of the larynx, 
one of membranous occlusion, two of cicatricial stenosis, one of 
rhinoscleroma, and one of tuberculosis. 

As regards the non-cancerous cases, though only two died shortly 
after the operation, I have no doubt it would be found on inquiry 
that repeated subsequent operations had to be performed on many 
of these patients, and that only a very small percentage can be 
shown to have made a complete and permanent recovery. It must 
not be forgotten, also, that in the case of children over three years 
of age suffering from benign growths, the little patients underwent 
a dangerous operation, when they might have been cured by one 
which presented no risk whatever. 

But to return to the subject of the ten malignant cases with which 
alone a fair comparison can be made, it must be remarked that they 
are all actually contained in my tables ! (See pp. 266, 268 and 270.) 
Readers will therefore be in a position to judge of the value of the 

* op. cit., p. 17. 
t Ibidem. 



234 CASE OF EMPEROR FREDERICK III. 

assertions of von Bergmann, and of his successful cases culled from 
the pages of the Cejitralblatt ! 

In Table No. i, p. 266, will be seen a collection of twenty-two 
cases of thyrotomy, six of which ended in death directly from the 
operation^ on or before the nth day. Of the remaining 
seventeen patients, ten had died * when the report was pub- 
lished, three suffered from recurrence of cancerous disease, 
and must therefore be looked upon as having died (though not 
actually dead when their cases were reported), two cases were pub- 
lished too soon after the operation to be of value for statistical pur- 
poses, and two recovered. That is to say, in twenty-two cases there 
were two cures, or in other words the percentage of recoveries was 
9*09, which is equivalent to saying that out of one hundred cases the 
operation proved fatal in nearly ninety-one ! I have myself never 
done this operation for cancer, though two patients of mine suffering 
from that disease (Table I, cases 5 and 7), who were operated on by 
other surgeons, died in seven months. I performed thyrotomy some 
years ago in a non-malignant case. The patient had suffered from 
increasing difficulty in breathing for some time, owing to the vocal 
cords having become united to each other throughout the anterior 
three- fourths of the glottis by a tough web. I had twice done an 
endolaryngeal operation on this patient, but though I had succeeded 
■in dividing the web on each occasion, the two cut edges had again 
become adherent. I therefore determined to slit up the web after 
dividing the thyroid cartilage, and I performed the operation at the 
Throat Hospital in the presence of my colleagues. In this case the 
patient would certainly have died by suffocation if nothing had been 
done, but I regret to say that the operation was not successful, death 
having occurred on the eleventh day from pleuro-pneumonia. 

Everyone knows that operations on the air-passages are very 
liable to be followed by inflammation of the lungs or their serous 
and mucous membranes, and in adults these complications much 
more frequently follow thyrotomy (division of the thyroid cartilage) 
than tracheotomy (opening of the trachea). It is absurd, therefore, 
to pretend that the operation is free from danger. The actual mor- 
tality, shown in Table I, p. 266, does not give an adequate idea of 
the risks attending it, for there are many hairbreadth escapes among 
the successful cases. Thus, in case No. i, according to Dr. Cutter's 
own words, " the return to complete sensibility was retarded by the 
accumulation of blood and mucus in the mouth, which ran down 
the trachea and out of the artificial opening. It was also accom- 

* Six patients died within ii days, one on the 13th day, and two in 7 months. Two patients 
lived a year, one 15 months, one 19 months, and one 22 months. In the case of one patient who 
committed suicide in despair at the recurrence of his disease, the date of the fatality is not given. 



DR. MACKENZIE' S REPORT. 235 

panied by profuse sweating and some flagging of the pulse." After 
the patient was put to bed " vomiting ensued, and a large amount 
of blood, mingled with mucus, was evacuated." 

In one of Prof. Navratil's cases,* the hemorrhage was alarming, 
and the patient nearly died under the knife, owing to the quantity 
of blood which passed down the trachea. In another of Navratil's 
cases the patient suffered from high fever after the operation, and 
expectorated a quantity of blood and pus; the parts round the 
wound became cedematous, and the patient was in a very critical 
state. 

In Prof, von Schrotter's casef the operator observed that after di- 
viding the thyroid cartilage, holding open the edges of the wound 
with blunt hooks " gave rise to such paroxysms of coughing, and 
caused so much fresh hemorrhage, that the examination could only 
be carried out for a short time; " and, further, " that the sputa con- 
sisted of pure blood, even well into the night, and on the following 
day the expectoration was still colored." 

Mr. Timothy Holmes remarks with regard to his case,| "that the 
parts over the larynx were found to be peculiarly vascular." After 
the hemorrhage caused by the preliminary incision had been checked, . 
the thyroid cartilage was divided. " The bleeding that followed was 
very considerable." 

Again, the reporter of Mr. Davies-Colley's third operation re- 
marks, § that "the boy at one time ceased to breathe, blood having 
apparently run down the trachea into the bronchial tubes, and the 
chloroform acting powerfully on the lungs. But after artificial 
respiration had been carried on for several minutes the little patient 
recovered." 

Dr. Fauvel, of Paris, pointed out,|| many years ago, that when the 
thyroid cartilage is divided in the median line, and the two sides of 
the larynx are held back or pulled outward, the opening is very small, 
not so large in fact as the (upper) natural opening of the larynx. If 
in order to obtain a very complete view the sides of the larynx are 
too forcibly pressed back, great injury is hkely to be done to the 
parts attached to the wings of the thyroid cartilage, and such injury 
would inevitably give rise to acute and dangerous inflammation. 
For this reason surgeons do not venture to force back the sides of 
the larynx (after thyrotomy) to any considerable extent, but are 
obliged to content themselves with a very imperfect view of the 
interior. 



* Berlin. Kim. Wochenschrift, December 7, 1868, p, 502. 
\ Medicin. Jahrbiich, Wien, i86g, vol xvii. zweite Heft, p. 81. 
t " Surgical Treatment of Children's Diseases," 2d ed., p. 311. 
§ British Medical yournal, September 28, 1872. 
II " Maladies du Larynx." Paris, 1876, p. 229. 



236 CASE OF EMPEROR FREDERICK III. 

Dr. Fauvel's exact words are : " The opening obtained by the 
separation of the two wings of the thyroid cartilage is so narrow that 
it is with difficulty one can introduce in the adult the blades of a 
closed forceps. It was impossible for us, in the case of the patient 
who is the subject of observation, No. 84, to separate the blades of 
a polypus forceps between the two thyroid wings in spite of the great- 
est efforts. We should certainly have produced fractures." In this 
case the operator associated with Dr. Fauvel was not a " rough and 
ready" surgeon, but the accomphshed M. Pean, one of the most 
briUiant and also the most careful of living operators. 

The operation of thyrotomy is by no means so harmless as it ap- 
pears, but like many other surgical procedures so readily undertaken 
at the present day, is attended with considerable danger. The 
fashion of reckless operating now in vogue owes its existence to a 
combination of circumstances, some of which may be easily over- 
looked. One of these is curiously enough the introduction of anti- 
septic methods. Nearly every great discovery is attended, however, 
with some drawbacks, and even the life-saving invention of Sir 
Joseph Lister, by rendering the conditions under which operations 
can be performed much more favorable, has resulted in some rash 
surgery. The conservative traditions of Fergusson, Nelaton and 
Langenbeck, have been forgotten, and as M. Verneuil remarks, at 
present, " if one surgeon cuts something, all his colleagues cut it, 
but in a different way." Dr. Gottstein, of Breslau, whose practical 
work on " Diseases of the Larynx" is now the best text-book deal- 
ing with these diseases which is published in Germany, remarks, 
(page 168): 

" The extirpation of malignant neoplasms by thyrotomy has, 
according to present experience, given very unsatisfactory results. 
In twenty cases collected by Paul Bruns, in two instances death 
occurred soon after the operation, and only in one case no local 
recurrence took place ; but here the fatal termination was due to 
cancer of the suprarenal bodies and of the left kidney. In all the 
other eighteen cases, local recurrence took place after a longer or 
shorter time, in a few cases indeed after two or three weeks, and 
only once was it delayed for one and a half years. There was 
never any mention whatever of a restoration of the voice after the 
operation." 

I repeat, it is only necessary for the reader who wishes to form an 
idea of the danger of the operation to look at Table I (Section III, 
page 266). This is the operation which von Bergmann says is no 
more dangerous than an ordinary tracheotomy ! This is the opera- 
tion which he assured the Crown Prince in May, 1887, was free from 
danger ! This is the operation from which the illustrious patient 



DR. MACKENZIE'S REPORT. 237 

was saved by my removal of a portion of growth and its subsequent 
examination by Prof. Virchow. 

The Inadequacy of the Operation. 

I shall now proceed to prove my second proposition, viz. : — (b) 
That the proposed operation does not afford a fair prospect of eradicat- 
ing a malignant growth, but, on the contrary, is most frequently fol- 
lowed by recurrence. 

The reason why this operation does not afford a fair prospect of 
success, is because it is nearly impossible by means of it to get 
away the whole of the growth. Hence in these cases recurre7ice 
appears to take place very soon after the operation. In speaking of 
recurrence, it is most important to remember that in cases of can- 
cer recurrence is the equivalent term of death. The patient soon dies 
when recurrence takes place, or his life may be rendered still more 
miserable by a second operation. 

In one of Hahn's three cases, recurrence is said to have taken 
place five weeks after the operation, but it is much more probable 
that in this instance the whole of the growth had not been got 
away. In another case the recurrence which took place was prob- 
ably very rapid, as the poor patient was so disappointed that he 
committed suicide. In the last case the patient died on the 
eleventh day before there had been time for recurrence to take 
place. 

In the cases contained in Table I, p. 266, recurrence took place 
twelve times, or, in other words, the rate of recurrence was 54*54 
per cent. This is the percentage in which the disease returned 
after an operation described by von Bergmann as promising the 
" best results ! "* It must not be forgotten, also, that in four out of 
the twenty-two cases operated on, death took place so quickly {i. e., 
in from eighteen hours to eleven days) that there was not time for 
recurrence. Had these unfortunate patients lived for a few months, 
and had the recurrence taken place in the same proportion in the 
four cases as in the others treated in the same way, the actual rate 
of recurrence would have been almost 90*0 per cent ! 

The fifth case in which death occurred as the immediate result of 
the operation is not included in this calculation, as the disease was 
found after death to be tuberculosis, and not cancer. As the oper- 
ation was performed for cancer, however, I have included the case 
in the tables. 

There is another point of less importance which may be just 
touched on here. I do not wish to attach too much weight to it, 

* op. czi.,p. 18. 



238 CASE OF EMPEROR FREDERICK III. 

because life is so incomparably more important than the preserva- 
tion of the voice that the latter is in the vast majority of cases an 
altogether secondary consideration. Special circumstances, how- 
ever, may modify this general rule. In the case of a parliamentary 
orator, a clergyman, a barrister, a singer, a military or naval officer 
— above all, in the case qf a future ruler, who has to be not merely 
an ornamental figure-head, but the real chief and imperator of a 
mighty army — the voice is of the utmost importance. Now what 
is the effect of thyrotomy {Laryngofissur) as regards the voice ? 
Fifteen years ago I published in the British Medical J^oi^rnal 
(April 26, 1873) a table which includes forty-eight cases, seven 
of which were malignant and the rest benign. Setting aside two 
cases which proved rapidly fatal, and one (Langenbeck's) in which 
the voice was not affected either before or after the operation, there 
remained forty-five patients. Of this number eighteen were com- 
pletely voiceless after the operation, whilst nine were dysphonic 
{i. e., hoarse) ; in five the voice was " modified ; " and in three, 
though the condition of the voice is not mentioned, there was a 
strong probability that aphonia or dysphonia existed. In only ten 
cases was a previously defective voice restored by the operation. 
In fact, the voice was destroyed or "modified" in 77*77 per cent, 
of the whole number ! 

As such a large proportion of the cases contained in my table 
were benign, the results of the operation, as regards the voice, were 
no doubt much more favorable than they would have been had all 
the cases been malignant, as the removal of a benign growth does 
not involve the sacrifice of so much of the structure of the vocal 
cord as is required for the effectual extirpation of a cancerous tumor. 

In dealing with the question of the extent of the growth in May, 
1877, von Bergmann adopts a method which is no doubt convenient 
from an argumentative point of view, but which can hardly be 
called straightforward. When he refers to himself as the operator, 
the growth is described* as " limited to the vocal cord." This is 
said to show ike very trivial nature of the operatio7i which would be 
necessary to effect a cure. When, however, I figure as the operator, 
and he wishes to show that it was impossible for me to remove the 
growth through the mouth, he states that it was not circumscribed, 
but that, on the contrary, it "affected the under side of the vocal 
cord and probably the side wall of the lower larynx.'" \ In discussing 
the chances of success in such an operation as he proposed to do, I 
have taken as the basis of my argument von Bergmann's first theory 
that the disease was strictly localized. If, however, we adopt his 

* op. cit., p. 19 

\ Ibid., p. 22. The italics are not in the original. 



DR. MACKENZIE' S REPORT. 239 

improved theory, it is clear, on his own showing, that instead of the 
operation set forth in Table I, p. 266, he would have found it 
necessary to perform the one described in Table II, p, 268. In 
this, although the actual mortality is not quite so great, the results 
are very discouraging. There are thirty-five of these operations, 
fifteen of which proved fatal. In these cases death took place in 
one instance on the fourth day, in one on the eleventh, in another 
on the twelfth, in one on the fifteenth, in two at the end of five 
weeks, in two others at the end of six weeks, in one case at the 
end of seven weeks, and in another after ten weeks. In one case 
death occurred after thirteen weeks, in one after four months, in one 
in thirteen months, and in two after sixteen months. 

Uncertainty of the Diagnosis. 

Having shown that the operation which von Bergmann proposed 
in May, 1887, soon leads to death, because, owing to want of 
sufficient access to the seat of disease, the growth is not thoroughly 
removed, and recurrence, therefore, speedily takes place, I pass to 
the consideration of my third proposition : 

{c) That the presence of cancer was not ascertained in the case of the 
Crown Prince until November., 1887, if, indeed, cancer really existed at 
that date. 

The truth of this proposition has been abundantly proved in the 
first section of this work. Even. Gerhardt does not profess to have 
been certain about the diagnosis in May, and as for Prof, von Berg- 
mann, I have already said that before my first visit to Berlin, he did 
not even pretend to have any opinion at all as to the nature of the 
disease. He disclaimed all responsibility for the diagnosis, his posi- 
tion in the case being, according to himself, simply to act on Ger- 
hardt's instructions. * The true nature of the growth could only be 
proved by microscopic examination, and as we have seen, none of 
the German doctors had been able to extract a piece of it for this 
purpose. I have myself never attached undue weight to micro- 
scopical evidence, but in doubtful cases it affords the only scientific 
test which we at present possess. I have pointed out in my work 
on "Growths in the Larynx "t that information afforded by the 
microscope is fallacious, but in doing so I meant to imply that an 
isolated examination could not always be relied upon. In the case 
of the Crown Prince the reports of Prof. Virchow afforded only 

* My authority for this statement is Dr. von Wegner, who, on two occasions during my stay at 
Charlottenburg, told me, that before my arrival in Berlin, Bergmann had always said, " Gerhardt 
makes the diagnosis. I am only the operator." 

t This work was publis ed in the year 1873. I had already then operated on over 100 cases, 
whilst the remaining cases published in the whole civilized world up to that date only amounted to 



240 CASE OF EMPEROR FREDERICK III. 

negative evidence ; but it must not be forgotten \}s\zX several examina- 
tions were made in the most careful way by the greatest hving 
pathologist. Great weight must necessarily be attached to them. 

The scientific world is more or less familiar with Virchow's re- 
ports, which, however, I have thought it well to publish again in full. 
(See pp. no, 117, 129 and 152.) Not only did the eminent patholo- 
gist fail to find any evidence of cancer in the portions submitted to 
him, but he went further, and said there was "nothing present in 
them which would be likely to excite the suspicion of wider and 
graver disease." Prof. Virchow not only called attention to the 
possible non-existence of cancer in any portion of the growth, but 
he pointed out that " the operation had reached the deep parts," 
and stated further that the microscopic features " characterize the 
lesion as an epithelial growth combined with papillary oflshoots 
(misnamed papilloma)," in fact djs, pachydermia laryngis, a purely be- 
nign kind of growth, or rather hyperplastic thickening. He ac- 
centuated his position by giving a lecture before the Berlin Medical 
Society on June 27, 1887, on pachydermia laryngis,* in which he 
let it be understood that he took the Crown Prince's case for his 
text. 

It will be seen, therefore, that I had every reason to hope that the 
disease was not malignant. In a case like that of the Crown Prince, 
I affirm, without fear of contradiction by any honest physician, that 
before consenting to an external operation which avowedly would 
have been more or less of the nature of a leap in the dark, I should 
have the clearest and most incontrovertible proof that the disease 
was cancer. 

There are two conditions under which a man may form an opinion 
— one in which that opinion is merely an academic one, and the 
other in which the opinion is to be followed by action of the most 
momentous character. Now, though theoretically it may be main- 
tained that the practical results which are to follow an opinion 
ought not to influence the formation of that opinion, common-sense 
demands a different conclusion. If action is to be taken — and 
especially if that action brings a human life into immediate danger — 
much greater certainty ought to be arrived at than if the opinion is not 
to be followed by any practical consequences. Thus a prudent general 
may be in doubt as to whether a certain defile is in possession of 
the enemy. He may believe that it is open, and if it is not neces- 
sary to make use of this gorge his opinion may not be weighed with 
the most minute care. If, however, he has to send" a detachment 
through the pass he must be absolutely certain either that it is un- 

* Berlin. Klin. Wochenschtift. 



DR. MACKENZIE'S REPORT. 241 

defended, or that he can force it before he allows his men to attempt 
the passage. A jury in giving a verdict ought to be much more 
certain of the proofs of guilt, if death is to foUow^ their decision, 
than if the punishment will merely be a few months' imprisonment. 
In the same manner, if the question of the nature of the Crown 
Prince's ailment had been merely an academic one, I possibly might 
have admitted that it was of a sufficiently suspicious character to be 
placed in the category of cancer ; but when my verdict was to carry 
with it the performance of an operation sometimes immediately 
fatal, and even when not immediately fatal, generally followed 
by a recurrence of the growth, and ultimately leading to 
more rapid death than if the patient had been left alone, 
I repeat, I required the most absolutely conclusive proofs. 
To put it in another way : a patient has a small hard lump in his lip 
which looks a little like cancer, though its nature is not by any 
means certain. Now we know that such a lump can be cut out 
without the smallest danger to the patient, and we know also, with 
almost absolute certainty, that the whole of the disease can be taken 
away. In such a case we naturally recommend the operation, even 
though it may not be at all certain that the little tumor is mahgnant. 
In the case of the breast again, the entire organ can be completely 
removed with little or no danger ; hence this operation is often per- 
formed in doubtful cases, and it is well known that many operations 
of this kind have been performed for perfectly harmless tumors. In 
the larynx, however, the very opposite conditions exist. There is 
danger in the operation itself, and the greatest uncertainty as to the 
complete removal of the disease. When the tongue is the organ 
affected the same argument applies. In a case of such transcendent 
importance as that in which I was engaged, I maintain, at the risk 
of reiteration, that before it would have been justifiable to perform 
an operation, not only highly dangerous in itself, but extremely 
uncertain in its results, the most positive evidence of its necessity 
was required. This, however, was not forthcoming. 

The pathological reports only show that scientific investigation 
has its limits. The one thing which has been added to our knowl- 
edge by this sad case is that, in cancer of the larynx, in very rare 
cases, a benign growth may co-exist with a cancer. These two condi- 
tions have been known to co-exist in cancer of other parts ; but the 
experience of Prof. Virchow, especially directed to that point, is 
that up to the occurrence of the Crown Prince's case, the two mor- 
bid conditions did not occur simultaneously in the larynx. Had 
this fact, however, been known before, I very much doubt whether, 
after the negative results of Prof. Virchow's repeated examinations, 
any surgeon would have ventured to perform an external operation 



242 CASE OF EMPEROR FREDERICK III. 

on the illustrious patient. Some people say that Virchow's reports, 
so far as they were objective, instead of disproving the existence of 
cancer, actually proved its presence. I may even say for myself 
that, had I received Prof. Virchow's reports without his comments, 
I should have come to this conclusion. When, however, so eminent 
a pathologist, a specialist whose position is unique in his own depart- 
ment, expressly declared that no such inference was to be drawn 
from the appearances he described, would it not have been absurd 
for me, a mere practical physician, to have set up my opinion 
against that of Virchow on a question of pathology ? 

Before proceeding to ask what would have been the probable 
result had von Bergmann operated in. May, 1887, I may be per- 
mitted to call attention to two very important circumstances. These 
are : First, that when it was known that I had removed a piece of 
growth, and that it was sent to Virchow for examination, Dr. Hahn 
(admitted on all sides to be the most experienced and successful 
operator on the larynx front the outside) remarked to Dr. Wegner 
that unless Virchow, or some other pathologist, found evidence of 
cancer in the portion of growth removed, he would not recommend 
an external operation to be performed. I must remind my readers 
that had Prof, von Bergmann performed the operation on the Crown 
Prince in May, 1887, Dr. Hahn had been engaged to be present in 
order to assist, or rather direct von Bergmann. It will be seen, 
therefore, that in the advice I gave I was supported by the most 
skilful operator of the day.* 

The second point to which I wish to call attention is that in Oc- 
tober, 1887, von Bergmann told Count Radolinski that in prevent- 
ing the operation in May I had done perfectly right. It is there- 
fore obviously unfair and unscientific for von Bergmann to attack 
me subsequently, from an ex post facto standpoint, because events 
did not turn out satisfactorily. t 

It must now be asked, what would have been the probable result 
if I had sanctioned the proposed operation in May, 1887 ? Von 
Bergmann objects to statistics being made the basis on which a 
judgment as to the justifiability of operations should be formed, 
and in view of the terrible results which have followed the various 
external operations on the larynx, I am not surprised that he should 
take up this position. He can have no objection, however, to my 
placing before my readers the results of the experience of so careful 
an operator as Dr. Eugen Hahn. As already remarked, this gentle- 

* This was told me by Dr Wegner in May, 1888, though in July, 1887, Dr. Wegner imparted to 
me a portion of the information in the Isle of Wight. 

t This information was given me at San Remoby Count Radolinski in November, 1887. It was 
mentioned by the British Medical yozirnaiot November 19, 1887, p. 1127, and has not been denied 
by von Bergmann. 



DR. MACKENZIE'S REPORT. 243 

man is admitted to be the most successful external operator on the 
larynx at the present day. He is indeed the only surgeon who can 
boast of any success whatever, and that success has, I understand, 
been obtained in great measure through his care in selecting cases 
which he thinks suitable for the operation. The public should 
understand that there are two classes of operating surgeons, viz. : 
those who operate in all cases where there is the smallest chance of 
success ; and those who refuse to operate unless there is every reason 
to expect a good result. There is a good deal to be said in favor 
of both classes. The bold surgeon, who operates in nearly every 
case that offers itself, no doubt from time to time has achieved some 
brilhant triumphs. On the other hand, the surgeon who operates 
only in cases of a very promising character obtains better results in 
the main than his rasher colleague. Dr. Hahn belongs to the 
category of careful surgeons. 

Let us consider the results of thyrotomy even in his careful hands. 
They can be seen at a glance in the subjoined table. 

Nothing could be more lamentable than this table. The first 
case is described as " cured," although the patient had to wear a 
canula afterward, or, in other words, was no better than if simple 
tracheotomy had been performed. Case No. 2 is described as 
" cured," although recurrence of the growth took place five weeks 
after the operation ! Let us follow up the case of this unfortunate 
patient. 

On May 5, 1887, less than five months after he had submitted to 
thyrotomy, total extirpation had to be performed (three weeks before 
the date on which it was intended to operate on the Crown Prince). 
The patient survived this procedure only four weeks. Here we 
have an example of what would in all probability have been the fate 
of the Crown Prince if von Bergman n had operated on him in 
May, 1887. His Imperial Highness would have suffered in May all 
the misery which he went through in the following February. 



Name of Patient. 


Result. 


1 Scheidenreicht 

2 Hahn* 


Cured (?) but could not dispense with canula. Recur- 
rence. Death from suicide. 

Cured. Recurrence 5 weeks after operation. 

Death on nth day through heart-failure. Operation 
only undertaken at urgent request of patient. 







* The patient's name was the same as the operator's. 



244 CASE OF EMPEROR FREDERICK III. 

Instead of this, as the result of Virchow's report, the illustrious 
patient passed many months of pleasant existence, during which he 
often told me that he felt as well as ever he had done in his life. 
If when the time came for tracheotomy to be performed tht after- 
treatment of that operation had been carried out in an intelligent 
manner, not only would the illustrious patient have been spared 
much unnecessary suffering, but his life would in all human prob- 
ability have been prolonged considerably beyond what actually was 
the case. The average duration of life in cases of laryngeal cancer 
is two years, and there are well authenticated instances of patients 
undoubtedly suffering from the disease having lived for three and 
even four years. Taking the average period, however, the Emperor's 
"expectation of life" was till about February, 1889. Thus several 
months of his existence were sacrificed through unskilful treatment 
and the use of clumsy instruments. 

Perhaps all the evil results ought not to be laid on the shoulders 
of Bergmann and Bramann, as the rapid development of the disease 
was in part probably caused by Gerhardt's extraordinary abuse of 
electric cautery. The slow progress of laryngeal cancer is uni- 
versally recognized, the hard incasing cartilage resisting the progress 
of the disease. In this case, however, Gerhardt's reckless use of 
the red-hot wire no doubt set up the perichondritis which formed 
such a orominent feature in the case and hastened the fatal result. 



CHAPTER XXV. 



THE INDICTMENT. 



The Witnesses. 

I propose now to pass briefly in review the various reports con- 
tained in the pamphlet in which my adversaries have embodied all 
their personal and professional grievances against me. Some points 
have necessarily been touched upon already in one or other of the 
foregoing chapters ; these I shall not again refer to unless further 
explanation may seem to be desirable for the sake of clearness. 

Before dealing with the individual statements, a few words must 
be said as to the reports collectively, in order that the reader may 
be in a position to judge between me and my accusers. A large 
part of the indictment against me rests on evidence which is utterly 
worthless, because it is adduced by witnesses who are either too pre- 
judiced to be altogether credible or too ignorant to be in any way 
competent. I am charged with having failed, or refused to see cer- 
tain appearances in the Crown Prince's larynx which should have 
opened my eyes to the real state of things long before the crisis at 
the end of autumn. The testimony adduced in support of this is : 
I, that of Prof. Gerhardt, who had the strongest personal reasons 
for painting the situation in the blackest possible colors; 2, that of 
Prof. Tobold, who throughout his brief connection with the case 
was simply the fidus Achates of Gerhardt ; 3, that of Prof, von 
Bergmann, who did not even pretend to see anything in the Crown 
Prince's throat beyond what he was told to look for ; and 4, that of 
Dr. Landgraf, whose determination to see somethiftg for himself 
resulted in the highly imaginative " observations " to which I have 
more than once alluded. At a later period equally valuable 
"observations" were made by Dr. Bramann and Prof. Kussmaul, 
which are now gravely brought forward as independent testimony 
outweighing that of specialists like Krause, Hovell and myself. I 
will do Prof. Kussmaul the justice to say that I do not think that he 
had any idea of posing as a laryngoscopist at San Remo ; his 
examination of the Crown Prince's throat was only intended as a 



246 CASE OF EMPEROR FREDERICK III 

sort of medical rite or ceremonial observance appropriate to the 
occasion. Bergmann, Bramann and Landgraf, however, whose 
laryngoscopic skill was just as much a quantite tie'gligeable as that of 
Kussmaul, were far from being so modest in their pretentions ; they 
went through the farce with the solemnity of Roman augurs, and 
had the results of their ;pro forma examinations duly added to the 
"official sources." The whole thing was a melancholy sham. The 
mere manual art of laryngoscopy can only be acquired by much 
practice, and when that has been mastered there are still many fal- 
lacies of observation which it requires considerable experience to 
guard against. ' It is therefore as preposterous that the " observa- 
tions " of a novice, who hardly knows how to hold the mirror, 
should be set against those of an expert, as it would be for me 
to claim the same importance for astronomical observations made 
by myself as for those of Sir George Airy or Mr. Christie. 

The " Official Sources. ^^ 

As the authors of the German pamphlet appear to claim some 
special authority for their production on the ground that it is drawn 
from " official sources," it may be as well to show exactly what that 
imposing expression means. The "official sources," as a matter 
of fact, largely consist of documents drawn up by those gentlemen 
themselves in their private capacity. These lucubrations are there- 
upon incontinently deposited (often, I imagine, without being read) 
in the state archives, where they acquire the proper odor of beau- 
racratic sanctity, and from which they are in due course brought 
forth as "official" documents of the highest importance. In the 
present instance, not only were the innumerable protocols and 
reports of various kinds, which we all had to send in from time to 
time, carefully deposited among the " official sources," but all the 
quack nostrums, miraculous waters, magical incantations, charms, 
talismans, phylacteries and relics, with the directions for their use, 
were solemnly stowed away in the proper pigeon-holes. Even 
the oatmeal malt extract, the essences and quintessences of beef, 
and all the infinite variety of patent articles of diet which were 
showered on the Emperor's doctors by humane persons or enterpris- 
ing tradesmen, were placed in the same official limbo. It will be 
seen that the word " official " covers a most heterogeneous collection 
of " documents," of very different degrees of historical value. 

As regards any opinions or statements attributed to me in 
"official" documents, I take this opportunity of saying that unless 
they are signed by me, they have no authority whatever. It is true 
that rough notes were taken at some of our earlier consultations by 
Dr. Wegner, but the fair copies embodying our several views were 



DR. MACKENZIE'S REPORT. 247 

never, I believe, submitted to the individual physicians and sur- 
geons for their perusal and signature. At any rate, I can speak 
with certainty for myself. No document embodying a precis of re- 
marks by me at a consultation was ever placed before me in order 
that I might say whether it gave an accurate account of my opinion. 

. The Evideiice : Gerhardfs Report. 

In dealing with Prof. Gerhardt's report, what must strike every 
impartial reader is, .hat he thought much more of protecting his 
own professional reputation than of benefiting the Crown Prince. 
As he could not himself extract a piece of the growth for micro- 
scopic examination he should have at once called in some one who 
could do so. There are at least half a dozen men in Germany who 
could have done this little operation which I subsequently performed. 
This, however, would not have suited the views of the professor, who 
accordingly invoked the aid of a general surgeon who could not be 
his rival in the laryngological field. When the illustrious patient was 
at Ems, Dr. Wegner already perceived that he had made a mistake 
in calling in Prof. Gerhardt, and expressed an opinion that a com- 
petent specialist ought to be summoned.* This, however, was pre- 
vented by Prof. Gerhardt, who insisted on Bergmann being sum- 
moned. At a later period, when for the sake of appearances a 
throat specialist had to be called in, instead of sending for one of 
the leading men in that line, a gentleman was chosen, who, on his 
own confession, " no longer operated ! " In this way Gerhardt hoped 
to hide his own incompetence. At a later period I had the honor 
of being summoned from London, not apparently because my 
opinion was likely to be of any value, but because " every person 
who knew how to make a laryngoscopic examination must come to 
the same conclusion " as Gerhardt had done ! The grounds on 
which I was called are thus clearly laid down. If the proposed 
operation had been performed and had proved successful, Bergmann 
would have said that the nature of the disease was quite clear; 
Mackenzie was only called in as a matter of form. If, on the other 
hand, the operation had proved fatal, Bergmann would have thrown 
the responsibility of the whole thing on me. 

The first charge brought against me by Prof. Gerhardt is that I 
took the forceps out of my pocket and used them without first dis- 
infecting them. As it happens, the instrument was contained in a 
silk bag lined with carbolized wool, which I have long used for the 
purpose. He further says that I was not able to throw the light on 
to the laryngeal mirror, but that it fell on the patient's cheek. Of 

* op cit., p. 5. 



248 CASE OF EMPEROR FREDERICK 111. 

course in reflecting a ray of light on to a mirror it must pass across 
the patient's face before it reaches the Uttle glass, and if Prof. Ger- 
hardt happened to notice it in its transit, that was certainly no fault 
of mine. That I could introduce forceps into the larynx at all with- 
out the larynx being illuminated is too absurd a theory for further 
consideration. 

I have already referred to Gerhardt's utterly baseless allegation 
that I had wounded the right vocal cord. At the time of the sup- 
posed accident, I understood that I was charged with nothing worse 
than clumsiness. In his published statement, however, Gerhardt 
goes altogether beyond his former amiable insinuation, and accuses 
me of having been unskilful of malice aforethought. He says,* 
" This must be the first case in which a laryngeal specialist has en- 
deavored\ by mistake to tear away a piece of a healthy vocal cord." 
I have only to say that the infamy of so disgraceful a charge recoils 
on the person who makes it. I am certainly at a loss to understand 
how a person can endeavor to do anything by mistake, but the im- 
pression which Prof. Gerhardt has tried to convey to the public is, 
I suppose, that, in order to mislead Virchow, and to get from him a 
favorable report on the portion removed, I endeavored to take away 
a piece of healthy tissue instead of the diseased structure. It would 
seem that Gerhardt thought the charge which he first made against 
me was not sufficiently damaging to my reputation, and that he 
therefore altered it. On this subject I need only say that on every 
occasion that any tissue was removed by me from the Crown Prince's 
larynx it was at once submitted to Prof. Virchow. As already 
remarked, that eminent pathologist pronounced every fragment ex- 
amined by him to be unquestionably diseased. 

Several of the other accusations he makes against me are hardly 
less remarkable for their combined absurdity and malevolence. 
Thus he actually states that " on the 24th of May it was already 
generally known that Mackenzie had promised the relatives of the 
illustrious patient to ctcre the disease in a few weeks^X Now every- 
body knows that the length of time required to cure benign growths 
is most uncertain, and that no laryngoscopist would dream of saying 
that a patient could with certainty be cured in a few weeks. The 
most that I ever said on this subject was, that if the disease was not 
cancer, I believed I should be able to cure it. I never referred to 
the question of time at all. Another ridiculous statement is, that I 
said that "the climate of the Isle of Wight would greatly assist in 

* op. cit., p. 9. 

t The italics are not in the original. 

J Op. cit , p. 10. '• 



DR. MACKENZIE' S REPORT. 249 

the cure" of the Crown Prince.* Prof. Gerhardt appears to be 
under the impression that the Isle of Wight is a place like Ems or 
Homburg where patients undergo " cures." I have already ex- 
plained how the Isle of Wight came to be chosen by the Crown 
Prince as a place of residence, and I could hardly have imagined 
that any one could have been so silly as to believe, or even profess 
to believe, that I recommended the chmate as beneficial in cancer. 

The Evidence: Prof, von Bergmajm's Report. 

Prof, von Bergmann appears in two different characters in the 
pamphlet : First, as the author of a separate report ; secondly, as 
the general editor of the whole publication. How far, in the latter 
capacity, he acts independently, and how far he is the mouthpiece 
of the other physicians and surgeons whose reports appear under the 
same cover, it is impossible for me to say. But I should imagine 
that several of his colleagues would hardly care to be responsible for 
the statements which appear in that portion of the work which is 
supposed to be under the supervision of von Bergmann. His own 
report may be conveniently considered under three aspects : First, 
a narrative of "facts" which does more credit to his imagination 
than to his memory ; secondly, complaints of the scandalous injus- 
tice of newspapers supposed to be inspired by me, and denials of 
responsibility for the still more outrageous utterances of papers, sup- 
posed to be inspired by him ; thirdly, miscellaneous polemics on 
more or less irrelevant topics. 

Various portions of von Bergmann's narrative have already been 
dealt with in the earlier chapters of this book. I need not, there- 
fore, do more than call attention to a few of the grosser misstate- 
ments. In speaking of the period immediately subsequent to the 
tracheotomy he says, " that [I] admitted that the first tube I had 
made at San Remo was too narrow in the bore to be used." This 
is absolutely untrue. I was not allowed to introduce my instrument 
because it was a trifle smaller than the one already in use. I pointed 
out that it would be much better to use a smaller tube which would 
stop the coughing and bleeding, than to wait for a new canula. (See 
Section I, p. 174.) But where Bergmann chiefly shows his mastery 
of the " scientific use of the imagination " is in his account of the 
events of the fatal day (April 12) which may, without exaggeration, 
be said to have sealed the doom of the suffering Emperor. The 
painful story has already been told (see pp. 198-204) and need not 
be repeated here. It is necessary, however, to point out the inac- 
curacies of the German surgeon's version as given in his report. 

* op. cit,, p. II. 



2 50 CASE OF EMPEROR FREDERICK III. 

He states that immediately after his arrival at the palace, 
on seeing the state the illustrious patient was in, he thought 
" there was no time to be lost, and with Mackenzie's consent 
[he] sent a servant to fetch Bramann " who was in his car- 
riage outside. As 1 have already said (p. 200) so far from the 
Emperor being on the point of suffocation, we found him quietly 
writing when we went to his room. Prof, von Bergmann, however, 
says, "I and my assistant were not the only ones who found the 
Emperor in a state of suffocation." Now though the professor cer- 
tainly did not find His Majesty in such a condition, it is quite true 
that his assistant did, as something had taken place before he ap- 
peared on the scene which had made a terrible change in the state 
of affairs. Prof, von Bergmann did not send for Bramann until he 
had thrice plunged his sharp-edged canula into the tissues of the neck in 
front of the trachea. Dr. Bramann therefore did not witness the 
unfortunate performance of his chief, though he must have been 
somewhat puzzled at the latter's failure to do a thing which he him- 
self did without the least difficulty. I observe that Bergmann seeks 
to corroborate his statement as to the Emperor's breathlessness by 
the testimony of Gen. von Albedyll, Gen. Bronsart von Schel- 
lendorfif, and Gen. von Winterfeldt, who, according to him, had 
noticed symptoms of " suffocation " during the day. These gentle- 
men are no doubt most distinguished officers, but the question is 
hardly a military one, and I really cannot accept their opinion on 
such a matter in preference to the evidence of my own eyes. I am 
glad to find one sentence of Bergmann's narrative which I can con- 
firm ; it is quite true that he held apart the edges of the wound, 
while his assistant introduced the tube. Bergmann seems anxious 
that he should receive full credit for this achievement, but it is not 
easy to see on what he grounds such a claim, for the difficulty with 
the canula had nothing whatever to do with the edges of the wound, 
and the professor's help was therefore quite superfluous. 

In connection with this incident an utterly false and calumnious 
statement appeared in the Kolnische Zeitung, from the pen of its 
Berlin correspondent, a Dr. Fischer, who for some months previously 
had supported von Bergmann in that journal in a very violent and 
aggressive manner. The whole occurrence was grossly misrepre- 
sented. Mr. Hovell was accused of having refused to go to the 
Emperor when summoned by the orderly on the night of iith-i2th, 
and it was asserted that in trying to insert the canula he had forced 
morbid matter into the windpipe and lungs. Further, that the 
Emperor was left from 10 o'clock on Wednesday morning (nth) till 
5 o'clock on Thursday evening (the 12th) entirely in the hands of the 
English doctors, when fortunately von Bergmann arrived in time to 



DR. MACKENZIE'S REPORT. 251 

save His Majesty's Ufe ! Mr. Hovell was obliged in self-defence to 
rectify a statement so damaging to his professional character, and in 
order to do so he had of course to give an accurate account of the 
facts, including von Bergmann's share in the proceedings. Mr. 
Hovell's letter was commented on in the BritisJi Medical Journal, 
whereupon Prof, von Bergmann took the extraordinary step of 
sending a communication to the Berlin Medical Society, of which 
the following is a copy : 

"On April 28, the British Medical Journal made these remarks : 
'As Prof, von Bergmann has not contradicted this statement (viz., 
that he had made a false passage) it may be accepted as true ; ' that 
is to say, because I am silent in the face of a statement of facts and 
of personal attacks, it shows they must be well founded. If the 
British Medical Journal were not a journal whose scientific value 
I prize very highly, I might still remain silent in the presence of 
such an accusation, but under the circumstances I must defend my- 
self. I am not silent because I am in the wrong, but because I, like 
every honorable British or German physician, do not talk publicly 
about what goes on at the bedside of my patients." It was naturally 
supposed when Prof, von Bergmann adopted such an unusual course 
as to make this attack on me at the Berlin Medical Society, that on 
a fitting occasion he would give some satisfactory explanation. 
Two months afterward he pubhshes a report, in which, instead of 
giving an explanation, he suppresses the true facts, and makes a 
statement which is absolutely false. 

If it was merely a question of credibility between Prof, von 
Bergmann and myself; if there was nothing more than my word 
against his respecting this matter, it might be difficult for the public 
to decide which version to accept. Fortunately for the sake of 
truth there are objective facts in the case which cannot be explained 
away by any sophistry. It can be proved that there was no bleed- 
ing whatever before Bergmann's arrival. It can also be proved 
that his forcible attempts to introduce the tube were followed by 
profuse hemorrhage, the blood running out of the wound in the 
neck and also down the windpipe, and causing violent coughing. 
Three days afterward the Emperor had a shivering fit. A day or 
two later still, an abscess is noticed in the tissues into which von 
Bergmann thrust his canula. The abscess extends downward, 
ounces of pus are secreted daily, the patient is harassed by constant 
coughing from the pus finding its way into the windpipe, and his 
strength is reduced by the profuse and continual discharge of mat- 
ter. At last he sinks and an immense abscess-cavity is found after 
death just in the place where Bergmann made the false passage ! 
The logic of these facts is irresistible. 



252 CASE OF EMPEROR FREDERICK III. 

As to the question of dealings with the press, the disgraceful 
attack on Mr, Hovell which has just been referred to, though 
utterly false in almost every detail, yet bore internal evidence of 
being founded on information supplied by some one who knew what 
had taken place. It was a complete breach of the truce in the 
newspaper warfare raging round the case which had been arranged 
at San Remo in the early part of March (see p. i8i), but which I 
must admit had never been kept by a certain section of the German 
press. Although dishonorable to the last degree in itself, it was an 
adroit manoeuvre from the strategical point of view. A serious 
injury had been inflicted on the Emperor, the effects of which it 
would be impossible to hide for any length of time. It was there- 
fore most important to throw the blame on the hated foreign doc- 
tors, and as the facts which had occurred in the daytime could not 
well be distorted, Mr. Hovell, who, being on night duty, would 
have no witnesses to appeal to, was made the object of attack. 
The Emperor himself, however, knew well who it was that had done 
him a grievous injury, and neither open slander nor malicious 
insinuation can deflect the terrible condemnation from the man to 
whom it was applied by the illustrious sufferer. One proof of the 
entile disregard for truth which characterized the whole article is 
too striking to omit. It was stated that Mr. Hovell, on being 
called, told the orderly that it was unnecessary for him to get up, 
and some further conversation between them was recorded. As 
Mr. Hovell does not speak a word of German, and the orderly 
does not know a word of English, it would be interesting to know 
how the conversation is supposed to have been carried on. 

Although this impudently mendacious account of the catastrophe 
appeared at so opportune a moment for Prof, von Bergmann's rep- 
utation, I am not prepared to assert positively that he himself in- 
spired it. It is possible that the orderly, who had been in the habit 
of "controlling" me (see p. 191), may have been the " ofiicial 
source " of the lie. A day or two later the Kreuz Zeitungxeieued. to 
the subject, and said that on the fatal 12th I was quite " rathlos" " at 
my wits' end," i. <?., quite at loss to know what to do, and Bergmann 
was again made to figure as the savior of the Emperor. These 
attacks were re-echoed in the provincial press, in still coarser terms. 
Feeling that definite imputations of so grossly personal a nature 
could not be passed over in silence without seeming to admit their 
truth, I had to insist on the Kreuz Zeitiing publishing a contradic- 
tion of the statement. The following is the letter I wrote, which, 
it will be seen, is very moderate in tone, and contains no allusion to 
the injury which Bergmann had inflicted on the Emperor : 



DR. MACKENZIE'S REPORT. 253 

" The remark that I was at my wits' end, and therefore sent for 
Prof, von Bergmann on Thursday the 12th instant, is absolutely 
false. The truth is that as Prof, von Bergmann has charge of the 
surgical treatment of His Majesty the Emperor conjointly with me, 
I thought it more courteous to the eminent surgeon to invite 
him to assist me in inserting a better fitting tube instead of 
one which no longer served its purpose. As Prof, von Bergmann 
seemed to wish to insert the new tube, I raised no objection. He 
was, however, unsuccessful, and the tube was finally inserted by 
Dr. Bramann. As my courtesy led to misrepresentation by you and 
others, I have since changed the tube when necessary or desirable 
without summoning Prof, von Bergmann." 

It would be tedious and not in the least instructive to follow 
Prof, von Bergmann through the various newspaper paragraphs he 
has collected. He seems to be extremely annoyed at a statement 
made in the Pall Mall Gazette that he has never had a successful 
case of complete or partial extirpation of the larynx. To this he 
replies that he has had seven cases of thyrotomy {laryngofissiir). 
It has already been pointed out that these operations were not done 
for cancer, and besides it may not be superfluous to emphasize the 
fact that thyrotomy is not the same operation as excision of the 
larynx. It now also appears tha" Bergmann has had one successful 
case of this latter operation in a patient suffering from cancer. His 
statement that whilst I was in Berlin he offered* to show me this 
patient has no more foundation than many others of his so-called 
facts. I never heard of the case till I read of it in the German 
pamphlet. Had I had the opportunity of seeing a patient cured 
by the professor, I should have examined him with the greatest 
interest and curiosity. 

Bergmann seems to hold me personally responsible for every 
paragraph which appeared in the English papers as to the illness of 
the Crown Prince. I am even taxed with having inspired state- 
ments which I knew to be false, about matters of no importance 
whatever. The professor's view, so far as I can make out, is that 
this was done simply from a disinterested love of lying, for the 
statements referred to could not by any possibility be of any service 
to me. He further states that it is proved from "official sources " 
that I was in the habit of receiving fourteen correspondents. This 
is absolutely false. I certainly gave some information to the repre- 
sentatives of three German newspapers, but the information was of 
a most trival character, viz., as to whether His Majesty had had a 
satisfactory night, or whether his appetite was good. So meagre 

* op. cit., p. 19. 



254 CASE OF EMPEROR FREDERICK III. 

was the information that I gave, that on the days when the bulletins 
were published the correspondents did not usually apply to me. So 
far from encouraging the representatives of the press, it is a well- 
known fact that I subjected myself to systematic misrepresentation 
by the correspondent of a leading English paper, because, after he 
had "placed his services at my disposal," I decUned to receive him. 

Why does not von Bergmann complete the story ? He could 
easily show, and let me add from "official sources," that i/iis paltry 
' charge against me was actually laid before the Emperor and, further 
the same unimpeachable " sources" show that His Majesty treated the 
charge with silent contetjipt. I may add that in order to neutralize the 
absolutely false reports made by the " reptile " press respecting the 
condition of the Emperor, if I had been able to speak the truth, 
not merely to the representatives of fourteen but of fourteen hun- 
dred or even fourteen thousand newspapers, I should have been 
more than justified in doing so. Sheer physical fatigue caused by 
my professional duties unfortunately compelled me to limit my in- 
terviews with the representatives of the press to the narrowest limits. 
I may, however, remark in conclusion, that the liberal-minded mon- 
arch, whom I had the honor to serve, was not only aware of my re- 
lations with some members of the press, but that, in the most im- 
portant journalistic episode in which I was concerned, he even con- 
descended to advise me. 

Dr. von Bergmann's virtuous indignation on the subject of co- 
quetting with the press is edifying even if not altogether convincing. 
Methinks the professor doth protest too much when he is not ac- 
cused, and not enough perhaps when he is. At any rate he has 
never answered my challenge in the British Medical Journal oi May 
12, 1888, p. 1032, where I openly charged him with having been in 
frequent communication with journalists, and mentioned specific in- 
stances in which this had taken place. Prof, von Bergmann, who 
was so eager to reply to a remark in the same journal not long be- 
fore, has never attempted to traverse the statements made by me in 
that letter. If he held himself as scrupulously aloof from the papers 
as he would have us believe, the faculty of " thought-reading " with 
regard to him whir h seems to have suddenly become developed in 
several " able editors," is little short of miraculous. Not only did 
they know by intuition what von Bergmann had said in consulta- 
tions with his colleagues, but they were able to record measures as 
having been actually adopted which had been proposed by the pro- 
fessor without, however, having been carried into effect ! 

Thus on the morning of the 19th of April, Dr. von Bergmann 
brought with him a piece of elastic tubing which he intended to 
pass through the canula. He then intended to withdraw the canula, 



DR. MACKENZIE'S REPORT. 255 

and, leaving the elastic tube in the throat, afterward to thread another 
canula over it, and pass a second one into the trachea. As it hap- 
pened, there was no occasion for this apparatus, Mr, Hovell having 
changed the tube without any difficulty during the previous night. 
The professor's ingenious device was, however, described in the 
JSfatiofial Zeitung on the following day, as having been adopted with 
the greatest advantage. At San Remo, Dr. von Bergmann dis- 
played histrionic talent almost equal to that of his brother 
professor, Gerhardt. He publicly ejected Dr. Goldberg, a repre- 
sentative of the Naiiotial Zeitung, from his room with appropriate 
Pecksniffian pantomime; but in spite of this the views which the dis- 
tinguished surgeon expressed at our daily consultations were unfail- 
ingly reproduced in the columns of that journal. It afterward turned 
out that the said Dr. Goldberg was the regular reporter of Berg- 
mann's lectures at Berlin ! When the Emperor was at Charlotten- 
burg, the National Zeitimg published the minutest details concern- 
ing His Majesty ; not only was the exact diet given, not only the 
frequency of the pulse, but even the number of respirations per 
minute. By a curious coincidence, when von Bergmann retired 
from the case these details no longer appeared in the National 
Zeitimg. Details it is true were put in, but they were invented by 
the ingenious reporter, and were wholly inaccurate. But the power 
of divination shown by this enterprising journal, with which von 
Bergmann "had no relations whatever," was even more remarkable 
in November, 1887. At that time the details of a conference be- 
tween Prof, von Bergmann and Prof. Gerhardt, which took place at 
the Haus-Ministerium, in Berlin, were reported in the National 
Z?//z/;?^ with such amazing accuracy that the "official" reports of 
the conference, which now appears in the German pamphlet, is 
identical in its language ! 

These facts are, I think, sufficient to show the value that should 
be attached not only to Prof, von Bergmann's own protestations, 
but to the disclaimers of the various editors who, " of their own 
accord, declared in the most solemn manner that [Bergmann] had 
never had any relations, direct or indirect, with them." There is a 
refreshing simplicity about the dilemma propounded by von Berg- 
mann, viz., that either these honorable gentlemen have "lied inten- 
tionally," or their solemn statement aforesaid must be received as 
gospel truth. I at least have no difficulty in deciding which of these 
alternatives is to be accepted. 

I have not space to follow Prof, von Bergmann in his somewhat 
discursive remarks de omnibus rebus et quibusdam aliis. His com- 
plaint that I failed to adhere to the arrangement made with my Ger- 
man colleagues has already been answered. (Pp. 119 and 120.) The 



256 CASE OF EMPEROR FREDERICK III. 

mystery which he seems to think underhes the fact of Gerhardt not 
having come to England in the Crown Prince's suite may of course 
appear as insoluble to Bergmann as it does to Gerhardt himself. I 
cannot profess to be able to dissipate the Cimmerian darkness in 
which this important matter is involved, but it strikes me as just 
within the bounds of possibility that the Crown Prince may not 
have cared to be accompanied by a man who had shown himself 
incompetent, indiscreet and obstructive. 

Prof, von Bergmann's views on the use of the microscope in 
medicine are of no particular interest to any one but himself. I con- 
fess, however, I cannot share the belief which he appears to enter- 
tain that his opinion or mine on a question of pathology is as good 
as that of a specialist in such matters. I may point out, however, 
that Dr. von Bergmann has entirely misrepresented the position 
which I took up at San Remo, as indeed I had maintained from the 
commencement, viz., that in a case of such importance the micro- 
scopic examination ought to be made by the leading German pathol- 
ogist. He says: "We could never understand the position of a 
doctor whose treatment could only be based on the section of an 
anatomist (microscopist), a position which carried out to its full conse- 
quences places the physician behind the post-mortem table ! " In 
other, words, von Bergmann insinuates that because I ask for a piece 
of the structure of a doubtful tumor to be examined with the micro- 
scope d7ififtg life, I am placing myself behind the post-mortem table, 
which means, if it means anything at all, that I am waiting for the 
death of the patient in order to discover the nature of his disease. 
Bergmann's logic appears to be quite as eccentric as his mode of 
handling tracheotomy tubes. 

The Evidence: Dr. Landgrafs Report. 

I need not waste words on this gentleman's report. The remarks 
which I have felt obliged to make in the earlier parts of this book 
as to his mode of making laryngoscopic examinations suffice to 
show the value which I attach to his " observations." The self- 
satisfied confidence with which his wonderful statements are made 
would be sublime if it were not ridiculous. Dr. Landgraf may by 
this time be an excellent laryngoscopist, but it is quite certain that 
when he was " controlling" me in the summer of 1887 he had not 
learned the rudiments of his art. Hence I am surprised to find that 
after I had removed the growth on June 26, the young Stabsarzt 
actually saw that it was no longer there. If he had said that it was 
twice as large as before, or had moved bodily over to the other side 
of the larynx, or perched itself on the top of the epiglottis, the dis- 



DR. MACKENZIE'S REPORT. 257 

covery would have been more in character. The following extract 
from Dr. Landgraf 's diary is a fair specimen of the whole: " I i)ro- 
posed to Dr. Wegner that we should induce His Imperial Highness 
to give orders that when Dr Mackenzie made any change in the 
treatment he should communicate the details and the special reason 
for it to Dr. Wegner. These details I proposed to take down 
every time in the form of a protocol. This proposal was declined 
by the party concerned.'' * As I was never consulted, I presume 
"the party concerned" means the Crown Prince. On the 25th 
of June, I find the following interesting entry : " I referred to the 
importance of repeated examinations for swellings of lymphatic 
glands, and discussed the chances of thyrotomy {laryngofissur) 
with one of the highest personages in the august circle." I will not 
trouble my readers with further extracts from this remarkable docu- 
ment. 

The following httle incident, which is related by Dr. Landgraf 
with the most portentous gravity, is thoroughly characteristic of the 
man. After he had made an examination of the illustrious patient's 
throat at Braemar, Mr. Hovell asked him what he saw. I do not 
know whether Mr. Hovell asked this question merely out of polite- 
ness, or whether he wished to ascertain what wonderful discoveries 
Dr. Landgraf had made. Mr, Hovell has practiced laryngoscopy 
during the last ten or twelve years, and I have never come across a 
more careful or more accurate observer. The young Stabsarzt, 
however, was under the impression that he was a much more skilful 
laryngoscopist than Mr. Hovell, and expressed his surprise that a 
gentleman who had had so many opportunities of examining the 
throat, should ask him for information ! It would indeed be mat- 
ter for surprise if any one who had ever seen Dr. Landgraf use 
the laryngoscope should ask him for information. 

The Evidence: Professor von Schroiter's Report. 

There is not much in Prof, von Schrotter's report that calls for 
special notice. There is, however, one important error in his evi- 
dence which is very unfair to Prof Krause. The exact words 
which Krause used in speaking of the diagnosis have already been 
given (see p. 144) ; instead, however, of quoting these words, von 
Schrotter saysf that " Krause strongly urged the possibility that it 
might not be a neoplasm but another disease." This was exactly 
the position subsequently taken up by Dr. Schmidt (see p. 145), and 

* Op.cit., p. 28. 

t op. cit., p 36. The exact words of our several reports, deposited in the archives of the Haus- 
Ministenum, ought certainly to have been published in the German pamphlet, the German physi- 
cians having had full access to the " sources," though it was absolutely denied to me. 



258 CASE OF EMPEROR FREDERICK III. 

it cannot be at all satisfactory to Prof. Krause that language used 
by Schmidt should be attributed to the wrong person. For some 
reason not explained, von Schrotter has omitted to explain his 
change of front as regards the total extirpation of the larynx. He 
writes, moreover, with a somewhat overwhelming sense of his own 
importance. The Olympian condescension with which he speaks of 
Krause, a laryngologist in every respect his equal except in point 
of age, as an " industrious young colleague," prepares us for the 
quasi-celestial wrath with which he seems to have regarded Hovell 
for daring to express a decided opinion. It does not seem to be 
admitted as a valid excuse for the English surgeon that his opinion 
was only given in reply to a direct question of the Crown Princess. 
It happened to differ from that enunciated by Prof, von Schrotter, 
and although that oracle himself changed his mind whilst he was at 
San Remo, Hovell's almost blasphemous presumption in expressing 
the opinion ultimately arrived at by von Schrotter has evidently not 
been forgiven. If I might venture to criticise one of the Viennese 
professor's dogmatic utterances, I would ask to be allowed to point 
out that, if I did not attempt to remove a fragment of the new 
growth for microscopic examination on this occasion, this was not 
in the least because he "pronounced categorically against it." The 
determination not to operate was come to before Prof, von Schrot- 
ter's arrival, and was based on the "angry" appearance presented 
by the larynx, which contra-indicated any manipulation with forceps. 

As Prof, von Schrotter's somewhat offensive airs of patronage 
with regard to Prof. Krause might mislead some people as to the 
relative merits of the two men, I think it right to point out that, 
although it is true that Prof. Krause was at one time a pupil of his, 
it is no less true the pupil has since shown himself capable of 
teaching the master. The value of Krause's practical work was 
publicly testified to by Prof, von Schrotter himself at the meeting 
of German naturalists and physicians in 1887, when he declared 
that whereas he had formerly entirely disbelieved in the possibility of 
the cure of throat-consumption, he had obtained results which he 
had never before thought possible, since he had adopted Prof. 
Krause's method of treatment. 

Since the year 1881, Prof. Krause has probably done more for 
the throat specialty than any living laryngoscopist, and the extent of 
his investigations has been by no means limited. His articles on 
Ozaena {Vvxhoid's Archiv, 1881) ; his researches on the Relation of 
the Cortical Substance of the Brain to the Larynx and Pharynx 
{^Archiv fur Physiologic, 1883); his experimental investigations on the 
Contraction of the Muscles Acting on the Vocal Cords {Virchow's 
Archiv, 1884); his work on the use of Lactic Acid in Laryngeal 



DR. MACKENZIE'S REPORT. 259 

Phthisis {Berlin, klin. Wochetischrifi, 1885); his highly suggestive 
remarks on Functional Disturbances of the Larynx in Diseases of the 
Central Nervous System {Archiv fur Psychiairie, 1886); his essays 
on the Early Symptoms of Lupus and Tuberculosis of the Pharynx 
{Berlin, klin. Wochenschrift) ; his philosophical paper on Reflex Nasal 
Neuroses, and his Experimental Investigations on the Trigeminus 
{Deutsche med. Wochenschrift), have attracted the attention not only 
of laryngoscopists, but of all scientific physicians. 

That in calling in Dr. Krause I had selected the most able repre- 
sentative of the laryngological specialty in Berlin is proved by the 
fact that the medical advisers of the Emperor William, when they 
sent another laryngologist to San Remo, did not choose one from 
Berlin, but summoned a physician from Frankfort. 

I can speak of Prof. Krause as a practical physician in the 
highest terms, having had the advantage of being associated with 
him for many months. His careful clinical observations, his con- 
scientious anxiety to do the best for his patient, his gentleness in 
the sick-room, formed a remarkable contrast to some of his German 
colleagues, and I shall always feel indebted to him for his valuable 
co-operation under most trying circumstances. I am happy to be 
able to say that the Emperor thanked me on more than one occasion 
for having recommended Prof. Krause to him. 

The Evidetice : Dr. Moritz Schmidfs Report. 
This document is of no scientific value, for it is based on the 
mythical observations of Landgraf, and has not even the merit of 
being a truthful report of what took place at San Remo whilst Dr. 
Moritz Schmidt was there. At the urgent desire of Dr. Schmidt, 
Prof, von Schrotter and I agreed that large doses of iodide of 
potassium should be administered, the ground for the use of this 
medicine being Dr. Schmidt's theory that the Crown Prince was 
suffering from a chronic contagious disease. Nevertheless Dr. 
Moritz Schmidt after his visit to Berlin and his conference with von 
Bergmatin, had the audacity to say that, " considering the gradual 
development of the disease since the loth of March, the age of the 
patient and the laryngoscopic appearances, I could only regard the 
malady as one of perichondritis developed through carcinoma." * The 
man who at San Remo strongly urged that the disease might be of an 
enthetic character, after his journey to Berlin could only regard it as 
quite a different complaint ! As if, however, to prove that he knew 
nothing whatever about cancer of the larynx. Dr. Schmidt has gone 
out of his way to say that " the course of the disease from the begin- 
ing to the end appears to have been a usual and typical one." t 

* op. cit., p 42. 
t Op. cit., p. 43. 



26o CASE OF EMPEROR FREDERICK III. 

Now everyone knows that the disease ran a most exceptional course. 
Even if the separation of sloughs and the complete heahng of the 
resulting ulcers were not very unusual features, the destruction of 
the whole of the larynx, with the exception of a portion of the 
epiglottis, is a thing absolutely unknown in medical literature. I 
challenge Dr. Moritz Schmidt to produce a single recorded case in 
which i\\Q _post-morte??i appearances were the same as those described 
by Virchow on the i6th of June, 1888. 

The Evidence : Reports of Profs. Kussmaul, Waldeyer and Bardeleben. 

These call for no comment as they contain no controversial mat- 
ter. Prof. Kussmaul's report confirms my statement that the only 
use of his visit to San Remo was to disabuse Bergmann's mind 
of an idee fixe which possessed him that cancer of the larynx is 
always complicated by cancer of the lungs. Prof. Waldeyer's report 
embodies the results of the careful microscopical examinations 
which led him to pronounce the disease to be cancer. Prof. 
Bardeleben's notes are little more than a diary of the clinical events 
whilst he was in attendance. 

The Evidence: Dr. Bramann's Report. 

Dr. Bramann does not seem to have been allowed to write a sep- 
arate report, but his observations and experiences are apparently 
contained in communications to Prof, von Bergmann. The prin- 
cipal object of his letters appears to be to set himself right with that 
surgeon, and to show that he was obliged to operate before he 
arrived. At the time of my visits to San Remo, I was not aware 
that Dr. Bramann was laboring under the misconception that he 
he had come to San Remo to act as a consultant with me. I 
thought that he knew that he was staying there solely as von Berg- 
mann's assistant to do tracheotomy if that surgeon could not arrive 
in time. When a physician is treating a case of laryngeal disease 
accompanied by dyspnoea, and when he does not intend to perform 
tracheotomy himself, he sends for the surgeon when he thinks the 
time has arrived or is nearly approaching for opening the windpipe. 
Of course the surgeon has a perfect right to refuse to do the opera- 
tion if he thinks that it is unnecessary. Thereupon the physician 
either yields to the views of the surgeon or calls in another operator. 
The position which von Bergmann's assistant has taken up, appears 
to be that when a physician is treating a case a surgeon is to be 
called every day or every other day to inform the physician when 
he considers it necessary to open the windpipe. Such an attitude 
is entirely novel, and in practice would be attended with difficulties 



DR. MACKENZIE' S REPORT. 261 

which need not be discussed here. According to Dr. Bramann's 
own statement, he received much of his knowledge regarding the 
state of the Crown Prince from the equerries in His Imperial 
Highness's suite. Dr. Bramann had the privilege of meeting these 
officers at a " Grog," which was held every evening at nine o'clock 
in the reading room of the Hotel Mediterranee. As the " clinical 
observations" of these military gentlemen appear to have been 
the basis on which Dr. Bramann has founded a large portion of 
his reports to Berlin, it is unnecessary to refer any further to his 
statements. 



SECTION III -STATISTICAL. 



CHAPTER XXVI. 



RESULTS OF RECORDED OPERATIONS. 



Statistics Sometimes Illusive, but not in this Instance. 

The paradox that " there is only one thing more misleading than 
facts, and that is figures," is accepted by many, and no doubt it has 
a certain amouut of truth for its basis. Facts can sometimes be so 
distorted, and figures so manipulated, that very misleading conclu- 
sions may be obtained. Fallacies are very likely to creep in in deal- 
ing with large masses of figures, especially when the problems are 
complicated. Again, statistics are often collected by persons whose 
competence to make the necessary observations on which those 
statistics are based is by no means assured. Hence, under certain 
circumstances, it is obvious that the accumulations of cases, instead 
of facilitating comparison, may render more obscure the questions 
which they are intended to elucidate. 

None of these objections, however, is applicable to the tables 
which are now brought under notice. The questions at issue are 
simple : viz., the duration of life after different kinds of operations 
on the larynx ; the reporters (in most cases the surgeons who have 
themselves performed the operations) are competetit. There are 
only two sources of fallacy ; one, that whilst surgeons nearly always 
report their successful cases, they do not invariably record those 
which terminate in death a few hours after an operation. Hence 
statistics of operations generally show more favorable results than 



DR. MACKENZIE'S REPORT. 263 

the real facts justify. The other source of fallacy lies in the diffi- 
culty of making an absolutely correct diagnosis even with the aid 
of the microscope. In the recent German pamphlet, Prof, von 
Bergmann (page 21) has attempted to ridicule the microscope as an 
aid to accurate diagnosis, or, indeed, as furnishing a mode of investi- 
gation which can in any way determine the kind of treatment to be 
adopted. Although this line of argument has been pushed to an 
absurd extreme, it is possible that the microscope does not always 
afford an absolute proof of the nature of the disease, even when the 
entire growth is submitted to examination ; and it is to be feared 
that in some cases patients have been inadvertently subjected to 
needless mutilation through the removal of a part or the whole of a 
larynx on account of the presence of growths which were not really 
malignant. I myself know of two cases in which surgeons removed 
the entire larynx without even taking the precaution to ascertain the 
nature of the disease by previously removing a portion endolaryn- 
geally, and in both these cases the extirpated larynx was found to 
be free from malignant disease ! 

To make these tables still more valuable there ought to be a fourth 
one, showing the duration of life of patients who have been affected 
with cancer of the larynx, and who have not had any radical opera- 
tion performed on them. Tracheotomy performed for cancer has 
not hitherto been considered a sufficiently interesting operation to be 
placed systematically on record, and the poor patient who gradually 
declines without any operation is also not considered to possess 
interest enough to have his case reported. Hence cases of cancer 
which have merely undergone tracheotomy, or have died without 
surgical treatment of any kind, do not generally appear in medical 
literature. The point at issue is : Does an external operation, and 
especially thyrotomy {laryngofissur) afford a reasonable prospect 
of effecting a cure, or of extending the duration of life for a longer 
period than leaving the patient alone until tracheotomy becomes 
necessary, if indeed tracheotomy should be required ? And in 
considering the question of radical operations, it is important to bear 
in mind, as just remarked, that, in many cases of cancer of the 
larynx, even tracheotomy can be dispensed with. The patient 
gradually gets weaker as the disease advances, and a large number 
of patients die without the necessity for tracheotomy arising. It 
need scarcely be pointed out that if this operation can be avoided, 
the euthanasia is greatly promoted. Hence in considering the 
question of performing the various more or less dangerous radical 
operations, it must not be considered that the comparison is in- 
variably to be made between one of these operations and a late 



264 CASE OF EMPEROR FREDERICK III. 

tracheotomy. The question really is, in many cases, between a 
radical operation and no operation at all. 

In dealing with the particular case under consideration, the main 
discussion must take place in connection with the question of 
thyrotomy, as that is the operation which von Bergmann alleges he 
intended to perform. In the published cases (see Table i, p. 266) 
in which thyrotomy was performed for cancer, the immediate 
mortality has hitherto been 27*2 per cent. The recurrence has been 
at the rate of 54*54 per cent, in those cases where the patient sur- 
vived the operation, but if four of the immediately fatal cases 
had lived for a few months and the recurrence had been in the 
same proportion in these cases as in the others, the rate of recur- 
rence would have been nearly 70 per cent. It should be mentioned 
also that in several of the cases where the patients lived for a few 
months,' they had to wear a tracheotomy tube from the day of the 
operation to the day of their death ; they were, therefore, in a much 
worse condition than if tracheotomy had been postponed to a late 
period of the disease. Only those who have witnessed all the at- 
tendant discomforts of tracheotomy can realize what this means. A 
canula worn on account of a stenotic cicatrix is of comparatively 
little inconvenience, but a tube worn where there is a broken down 
malignant growth in the larynx is often very distressing. In con- 
sidering the question of thyrotomy, it must not be forgotten also that 
if the operation is not successful, and 07ily two cases have ever bee7t 
reported in which the operation has been successftd (viz., cases 10 and 
17, Table I.), the disease is aggravated by the operation, more 
rapid development takes place, and the patient dies much sooner 
than if no operation had been done. It will be seen, therefore, 
that by thyrotomy, not only are a certain number of patients killed 
directly by the operation, but in n-early every case life is considerably 
shortened by that operation, whilst the conditions of existence 
during that shorter period of remaining life are much less pleasant 
to the patient than if no operation had been done. Against this we 
have the chance of a cure. But what a chance ! It is said that the 
prospects of recovery are almost 10 per cent., because out of 
twenty-two recorded cases two patients recovered, but there is 
every probability that if the twenty-two cases were made up to one 
hundred by further operations, no other cures would be found. 

In considering the question of success, no patient suffering from 
malignant disease can be considered cured unless the patient lives at 
least two years* after the operatio7i, because that is the length of time 
a patient may expect to live without an operation. But such is the 

; « . __. . 

* Three years is now the time accepted by surgeons in dealing with cancer of the tongue. 



DR. MACKENZIE'S REPORT. 265 

fell nature of cancer, that it often returns even after two years, and 
some of the highest living authorities go so far as to say that if the 
disease does not come back it proves that it was not cancer for 
which the operation was done. 

The advantages and disadvantages of each method may be put in 
parallel columns: 

Palliative Treatment Radical Treatment 

(including Tracheotomy). (Thyrotomy). 

Life is preserved under almost Life is sacrificed at once as the 

normal conditions for at least one year; result of the operation in 27"2 per 
and in a less favorable state for at least cent, of cases ; whilst in over 54-54 
one year longer, 2. d-., altogether for two per cent, death is hastened owing 
years. to the greater activity of the morbid 

process set up by the operation; and 
in these cases the condition of existence 
is rendered less favorable by the pre- 
mature use of a tracheotomy tube, 
necessitated by unsuccessful thyrotomy. 
A complete cure has been t-wice 
obtained. These cases are No. 10 
and No. 17, Table I. 

A few remarks are necessary in connection with the following 
tables, which are based on my own {Brit. Med. jFournal, April 26, 
and May 3, 1873), those of Norris Wolfenden {J^ournal of Lary?t- 
gology, vol. i, December, 1887 ; vol. ii, January and May, 1888), 
Hahn {Berliner Klinische Wochenschrift, No. 44, p. 919, 1887), 
and Scheier {Deutsche Med. Wochenschrift, 7th June, 1888), I 
have included the following six cases of Billroth which Scheier seems 
to have overlooked, viz., four cases of thyrotomy, table I, Nos. 6, 8, 
9 and 10, and two cases of total extirpation, table III, Nos. 21 and 24 
{Archiv. fiir Kli?iishe Chirurgie, vol. xxxi, p. 848). I have also 
added one case reported by Studenski of Kasan (Russia) {Central- 
blatt fiir Laryngologie, June, 1885, p. 398), two cases reported by 
Dr. Baratoux {Progres Me'dical, 1888), and five cases suppHed to me 
by Dr. Pelechin, Professor of Surgery at the Imperial Academy 
(Petersburg). 

My table was originally published fifteen years ago to show the 
results of thyrotomy in cases of growth in the larynx, whether malig- 
nant or benign. In the present summary, however, of course the 
benign cases have been excluded. In the same way from Hahn's 
and Scheier's tables, all cases of benign disease, cicatrices, etc., have 
also been omitted. 



266 



CASE OF EMPEROR FREDERICK III. 



TABLE I.— THYROTOMY {Laryngofissur). 

The operatio7i Prof. Bergmann says he intended to perform. — This 
table refers to the operation which von Bergmann says {op. cit., 
p. 19) he intended to perform, and which he affirms (p. 20) 
" does not threaten hfe." 



'0 a 


Operator. 




13 
0% 


Disease. 


Subsequent History. 


riU 




s'.ai 








:? 




SI 


q'^ 






T 


Gordon Buck. .. 


1851 


Carcinoma. 


Death in 15 months, a second 












operation having been neces- 












sary. 


2 


Sands . 


30 


i«S5 


<< 


Death from recurrence 22 








months after operation. 


3 


Gibb and Holt- 
has se. 


29 


1864 




Death in i year, recurrence 
having taken place at 4th 
month. 


4 


Schrotter 


63 


1869 




Death in 1 1 days of erysipelas 
and gangrene, growth not ex- 
tirpated. 


5 


Mackenzie and 
Wordsworth. 


47 


1869 




Death in 7 months, recurrence 
in 2 months. 


6 


Billroth 


56 


1870 


Epithelioma? 


Death on 7th day; diagnosis 
corrected post-morte7n as 
laryngeal tuberculosis. 


7 


Mackenzie and 
Thornton. 


24 


1872 


Carcinoma. 


Death in 7 months, recurrence 
in 4 months. 


8 


Billroth 


36 


1874 


<( 


Death in 8 months. Recur- 
rence took place in i month 
when total extirpation was 
performed. See table III., 

No. I. 


9 


Billroth 


26 


1880 


<( 


Death from hemorrhage on 
13th day, total extirpation 
having been done on 3d day 
for Recurrence. See table 
III., No. 24. 


10 


Billroth 


4S 


1881 


Carcinoma. 


CURE. Well 3 years after. 


II 


Studenski, Kasan 
(Reporter). 


56 


1883 


'* 


Death 8 months afterward. 


12 


Solis-Cohen 


63 


1884 


Epithelioma. 


Death in 19 months, recur- 
rence in 3 months. 


13 


Hahn 


51 


1884 




Death by suicide; the patient 
hanged himself in despair 
















when recurrence took place. 


14 


Billroth 


66 


1885 


a 


Death 18 hours after operation 
of oedema of the lungs. 


15 


Billroth 


40 


1885 




Death 10 days after operation 
of pysemia. 



DR. MACKENZIE' S REPORT. 
Table I. — Continued. 



267 



oCJ 


Operator. 


a 

43 
<: 


■a 

si 

■" s* 


Disease. 


Subsequent History. 


16 
17 

T8t 


Billroth 

Billroth 

Salzer . 


63 

41 

41 

37 
37 

45 
64 


1885 

1885 

1885 
1886 
1887 

1887 
1888 


Carcinoma. 

Epithelioma. 
Carcinoma. 

Epithelioma. 
Carcinoma. 


*Recurrence in 13 months, 
date of death not given. 
Total extirpation declined. 

CURE. No recurrence 2 years 
and 9 months after operation. 

No recurrence in 3 weeks. 

Recurrence in 5 weeks. 

Recurrence in 3 months in 
same site. 

No recurrence in 4 weeks. 

Death on nth day after opera- 
tion, attributed to heart 
failure. 


19 

20 


Hahn 


Cohn 


2lt 
22 


Stewart 

Hahn 







* The disease being cancer all cases of recurrence might be entered as death (with or without a 
second operation). 

t Except as showing that the operation was not immediately fatal, these two cases have no 
statistical value. 



ANALYSIS OF TABLE I. 

Death, it will be seen, took place in six cases as the immediate* 
result of the operation,* in one instance in 18 hours, in one in 7 days, 
in another in 10 days, in two instances in 11 days, and in one in 13 
days. The immediate mortality -was therefore 6 in 22 cases, 
or 27*2 per cent. In the remaining cases the operation was suc- 
cessful twice. Five patients died within the year, whilst 3 lived 
respectively 15 months, ig months, and 22 months. In three cases 
the patient had to submit to a second operation ! 

Recurrence is known to have taken place in 12 cases out of 22, 
or S4'54 per cent., more than half the cases ; but if we allow for the 
same rate of recurrence in the cases which terminated immediately in 
death as in those which survived for a short time, the rate of recur- 
rence would be nearly 70 per cent., or if, as is probable, recurrence 
took place in Studenski's case, the rate would have been almost 74- 
per cent. 

Success took place in 2 out of 22 cases, or, in other words, in 
9 09 per cent. These are the only successful cases which 
are known to have followed the operation of thyrotomy. 

* Deaths occurring within six •weeks of the operation are considered as due to the operation itself, 
and are therefore called imtnediate. Such cases, however, it will be seen, usually terminated much 
more quickly. 



268 



CASE OF EMPEROR FREDERICK III. 



As already remarked (p. 264), there is every reason to believe that if 
the 22 cases were made up to 100 by further operations no additional 
cures would result. The percentage of cures would be only 2, repre- 
sented by the two successful cases which have ever oc- 
curred. 

TABLE II.— PARTIAL EXTIRPATION OF THE LARYNX. 

A less unfavorable operation. — This is the operation which, bearing 
in mind Prof, von Bergmann's admission {pp. cit., p. 21), he 
would probably have found it necessary to perform. 



6U 



II 
12 

13 

14 

16 
17 

18 
19 



Operator. 



Billroth 

Reyher 

Billroth 

Schede 

Skliffkowski . . 
Wagner 

Hahn 

Billroth 

Billroth 

Billroth 

Billroth 

Hahn 

Stoerk 

Bergmann 

Billroth 

Salzer 

Salzer 

Salzer 

Salzer 



c 

< 


0°° 


50 


1878 


^? 


1880 
I88I 


42 

47 
53 


1882 
1882 

1883 


54 


1883 


60 


1883 


60 


1884 


58 


1884 


46 

53 


1884 
1884 


46 

65 
60 


1885 
1885 
1885 
1885 
1885 


58 
41 


1885 



Disease. 



Epithelioma, 
Carcinoma. 



Epithelioma. 
Carcinoma? 



Epithelioma. 
Carcinoma. 



Epithelioma. 
Carcinoma. 



Epithelioma. 



Subsequent History. 



Death in 16 months, recur- 
rence took place in 6 months. 

No relapse in 14 months. 

Death 5 weeks after operation, 
sepsis. 

Still living 1 7 months after. 
*Recurrence in 3 months. 

Death on 12th day after oper- 
ation. 

Death in 16 months after sec- 
ond operation rendered neces- 
sary by recurrence. 

Death in 5 weeks after oper- 
ation. 

Alive 3 months after, but 
obliged to wear canula. 

Death, recurrence having taken 
place in 7 weeks afterward 
invading glands. 
tReported cured in 6 weeks. 

Death in 4 days of pneumonia 
or mediastinitis. 

Alive in November, 1887. 

Alive in 1886. 

Result unknown. 

Death in 5^ weeks of pyaemia. 

Death in 6 weeks of pneu- 
monia. 

Recurrence in 7 weeks. 

Recurrence in 2 months. 



* The disease being cancer all cases of recurrence might be entered as death (with or without a 
second operation). 

t "Cured in 6 weeks" has no meaning except that the patient was not killed by the operation. 



DR. MACKENZIE' S REPORT. 
Table II. — Continued. 



lij^ 







c 








° rt 


Operator. 


'S-s 


« g- 


Disease. 


Subsequent History. 


dU 




mO< 


Q^° 






;z; 




< 






20 


Pick 


-■ 


1886 


Carcinoma. 


Death in 10 weeks after oper- 
ation. 


21 


Socin 


S6 


1886 


" 


Death in 13 weeks, a second 
operation became necessary 3 






















weeks before death. 


22 


Hahn 


6S 


1886 


(< 


Death on nth day. 
Cure. 


23 


Hahn 


52 

50 
61 


1886 


Epithelioma. 


2^ 


Butlin 


1886 


Living 5 months afterward. 
Death in 13 months. 


2"; 


Lennox Browne, 


1886 


<< 


26 


Kraske 




. - - . 


Carcinoma. 


Recurrence in 16 months. 


27 


Kraske 


.. 




n 


Recurrence in 4 months. 


28 


Mickulicz 







<c 


Living a year after operation. 


2Q 


Pean 


53 


1887 


EpitheUoma. 


*Death on 15th day of strangu- 
lated hernia, Recurrence 
















had taken place. 


30 


Hahn 


43 


1887 


<< 


Death on 15 th day. 
Living one year afterward. 


31 


Simanowski 


Carcinoma. 


32 


Hahn 


36 


1887 


(( 


No recurrence in 5 weeks. 


33 


Rushton Parker, 


39 


1887 


EpitheUoma. 


Death 4 months afterward. 


34 


Multanowski . . . 


47 


1882 


Carcinoma. 


Recurrence in 3 months. 


35 


Hahn 


42 


Feb. 
1888 




tSubsequenttracheotomy; glands 
much enlarged. 



* Although this patient died fifteen days after the operation it is not included among the deaths 
immediately resulting from this procedure At the same time it is by no means uncertain that the 
coughing following the operation was not the real cause of the hernia becoming strangulated. 

t Personal information from Berhn correspondent, 28th of July, 1888. 

ANALYSIS OF TABLE II. 

This table shows that of thirty-five operations fifteen proved fatal, 
that is 42-85 per cent. 

Death, it will be seen, took place as the immediate result of the 
operation in eight cases, in one instance on the fourth day, in one on 
the eleventh day, in another on the twelfth day, in one on the fifteenth 
day, twice in five weeks, in one case in five and a half weeks, and in 
one in six weeks. The immediate mortality -was, therefore, 8 
in 35 cases, or 22-85 per cent. In the remaining cases, where 
death had occurred at the time the report was pubHshed, the fatal 
issue took place: once in 7 weeks, once in 10 weeks, once in 13 
weeks, once in four months, once in 13 months, and twice at the end 
of 16 months. In the remaining cases no details are given, or the 
patients were living at the time the report was issued. One patient, 
as seen below, has lived 2 years. 



270 



CASE OF EMPEROR FREDERICK III. 



Recurrence is only reported to have taken place in nine cases, 
but there is no information in many of the cases on this point. One 
case (No. 4) is described as still living; in another (No. 10) the 
patient was still " obliged to wear the canula," showing either that 
there was incomplete removal of the growth at the time of the oper- 
ation, or that immediate recurrence took place. Another case is re- 
ported as cured at the end of 6 weeks, which merely means that the 
patient did not die from the immediate effects of the operation. In 
another case (No. 15) the result is " unknown ; " in fact, in this table 
the actual rate of recurrence cannot be determined. It is probable, 
however, that recurrence does not take place nearly so frequently after 
this operation as in the case of thyrotomy, because partial extirpation 
affords much more favorable conditions for removing the entire 
growth than is obtained by simple thyrotomy. 

Respecting case No. 35, I heard on July 28, 1888, from a Beriin 
correspondent, that the patient operated on by Dr. Hahn in February 
was readmitted to hospital on April 7 with great dyspnoea. Trache- 
otomy had to be performed. The glands on both sides of the neck 
were said to be much swollen. 

Success* occurred in one case (No. 23) out of 35 cases, or 2*85 
per cent. This operation will probably be found to be much more 
successful than simple thyrotomy for the reasons just stated in deahng 
with the subject of recurrence. 



TABLE III.— TOTAL EXTIRPATION OF THE LARYNX. 

A7t operation which, when not immediately fatal, leaves the patient 
in a state of abject misery. This is one of the operations 
brought under the consideration of the Crown Prince in No- 
vember, 1887. 





Operator. 




.2 


Disease. 


Subsequent History. 


I 
2 

3 
4 


Billroth 

Heine 

Maas 


36 

57 
56 


1S73 

1874 
1874 
1874 


Carcinoma 
(recurrent). 

Epithelioma. 


Death in 7 months ; recurrence 
took place in i month. See 
table I., No. 8. 

Death 6 months after from re- 
currence. 

Death 13 days after op. pneu- 
monia. 

Death on 4th day ; collapse. 


Schmidt 



* As already remarked (p. 264), by success is meant the survival for over 2 years. 



DR. MACKENZIE' S REPORT. 
Table III. — Continued. 



271 







c 








° s 


Operator. 


o-s 


a "Ph 


Disease. 


Subsequent History. 


rSU 




ft'nOi 


"In S 






% 




< 






S 


P. H. Watson.. 


60 


1874 


Epithelioma. 


Death in 2 weeks ; pneumonia. 


6 


Schontorn 


72 


1875 


Carcinoma. 


Death on 4th day. 


7 


von Langen- 
beck. 


57 


1875 


" 


Death by collapse ; recurrence 
in 4 months. 


8 


Multanowski . . . 


59 


1875 


(C 


Death in 3 months; pneu- 
monia. 


9 


Multanowski 


47 


187s 


(C 


Death, with recurrence in 2 
months. 


10 


Billroth 


54 


1875 


<c 


Death on 4th day ; pneumonia. 


II 


Maas 


50 


1876 


Epithelioma. 


Death in 6 months from recur- 






rence. 


12 


Gerdes 


76 


1876 


Carcinoma. 


Death in 4 days ; collapse. 


13 


Reyher 


60 


1876 


'^ 


Death on nth day; pneu- 
monia. 


14 


Watson 


60 


1876 


Epithelioma. 


Death in 7 days. 


15 


Kosinski 


3& 


1877 


" 


Death in 9 months; pneu- 
monia. 


16 


Wegner 


52 


1877 


(( 


No recurrence in 8 months. 


17 


Landerer 


45 




Carcinoma. 


Death 4 months after recur- 
rence and secondary deposits. 


18 


Bottini 


48 


1877 


Epithelioma. 


Death 3d day ; pneumonia. 


19 


von Bruns 


54 


1878 


" 


Death 9 months after recur- 
rence. 


20 


Billroth 


43 


1879 


(f 


Death 7 weeks after. 


21 


Billroth 


60 


1879 


Carcinoma. 


Death 3d day ; pneumonia. 


22 


Macewen 


56 


1879 


<( 


Death 3 days after; pneu- 
monia. 


23 


von Langen- 
beck. 


78, 


1879 


<< 


Death in 3 days ; collapse. 


24 


Billroth 


26 


1880 


(recurrent). 


Death from hemorrhage on 9th 
day. See table I., No. 9. 


2S 


Multanowski 


60 


1879 


(1 


Death in 5 days; pneumonia. 


26 


Reyher 


48 


1880 


" 


Death on 7th day; pneumonia. 


27 


Thiersch 


36 


1880 


<< 


Death in 18 months, after 
second operation for recur- 
rence. 


28 


Thiersch 


52 


1880 


<( 


CURE. Was living 3^ years 
after. 


29 


Czerny 


47 


1880 


Epithelioma. 


Death in 5 months ; recurrence. 


30 


Thiersch 


45 


1880 


Carcinoma. 


Death 19 weeks after operation. 


31 

32 


Hahn 


68 


1880 


? Cancroid. 
Carcinoma. 


No recurrence 1 1 months after. 


Bohmer 


Death in 12 hours; oedema of 












lungs. 


33 


Hahn 


53 




(< 


Death in 4 days; pneumonia 
and mediastinitis from push- 


















ing canula into mediastinum. 


34 


Bircher 


49 


1880 




Death in 16 days of pneumonia. 





272 CASE OF EMPEROR FREDERICK III. 

Table III. — Continued. 









.2 








Operator. 


'0-43 




Disease. 


Subsequent History. 


60 




mPh 


a°° 






!? 




< 






SS 


Hahn 


68 


1880 


Carcinoma. 


CURE. No recurrence in 1 888. 


36 


Hahn 


46 


1881 


it 


Death on 25th day ; gangrene 
of lungs. 








37 


Toro 




1881 


Epithelioma. 


Death in 4 days; pneumonia. 


3« 


Pick 


39 


1881 


c< 


Death on 5th day; pleuro- 
pericarditis. 








39 


Thiersch 


57 


1881 


Carcinoma. 


Death 7th day; pneumonia. 


40 


Winiwarter 


55 


1881 


<( 


CURE. Patient well in 1884, 
3^ years after. 


41 


Czerny 


47 


1881 


Epithelioma. 


Death 10 months after from 
recurrence. 


42 


Reyher 


57 


1881 


? Carcinoma. 


Death 5th day; pneumonia. 


43 


Kocher 


59 


1881 


? " 


Death in 2 years from cancer 
of abdomen. 


44 


Tilanus 


51 


1881 


Epithelioma. 


Death in 36 hours ; collapse. 


4'; 


Gussenbauer 


48 


1881 


«' 


CURE. Living in 1886. 


46 


Voelker 


44 


1881 


Carcinoma. 


Death in 5 months from recur- 
rence. 


47 
48 

4Q 


Albert 


46 
36 


1881 


<< 


Death 8th day; pneumonia. 
Death 25th day; bronchitis. 
Recurrence in 3 months. 


Hahn 


1881 


a 


Marjary 


1881 


" 


SO 


Gussenbauer 


62 


1881 


Epithelioma. 


No recurrence in 14 months. 


SI 


Gussenbauer . . . 


t^ 


1881 


Carcinoma. 


Recurrence in 6 months. 


52 


Reyher 


72, 


1881 


" 


Death 9 months after recur- 
rence. 


53 


Novaro 


63 


1881 


Epithelioma. 


Death 5 months after second 
operation; recurrence took 
place in 4 months. 


54 


Schede 


54 


1881 


Carcinoma. 


Death by suicide at 7th 
month, recurrence having 
taken place 


55 


Chiarella 


41 


1 881 


C( 


Recurrence in 4 months. 


56 


Maurer 


47 


1882 


(( 


Death 5 months after Irom re- 
currence. 


57 


Hahn 


43 




Epithelioma. 


Death 14 months after; 9 sec- 
ondary operations for recur- 
















rence had to be done. 


5« 


Schede 


54 


1882 


Cancroid. 


Death by suicide in 8^ months, 
on recurrence. 


59 


Maurer 


47 


1882 


Epithelioma. 


Death from recurrence after i 
year. 


bo 


Chiarella 


52 





Carcinoma. 


Recurrence in 2% years (?) 


61 


Sokotowski 


62 


— 


(( 


Death 8 weeks after opera- 
tion ; pneumonia. 


62 


Chiarella 


72 





" 


Death 8 months after. 


63 


Chiarella 


65 


" ' * " 




Death 13^^ months after oper- 
ation from asphyxia. 



DR. MACKENZIE'S REPORT. 
Table III. — Continued. 



273 









.2 










c 


•^ rt fi" 






° cS 


Operator. 


O'-S 


°p 


Disease. 


Subsequent History. 


6U 




a^ 


«og 






;z; 




<; 


Q 






64 


Reyher 


65 


1 881 


Carcinoma. 


Death 7th day from septic 
pneumonia. 


65 


Reyher 


55 


1882 


" 


Death 14th day from exhaus- 
tion. 


66 


Holmer 


57 


1882 


Epithelioma. 


Death 7 months after from 
recurrence. 


67 


Kocher 


54 


1882 


Carcinoma. 


Recurrence in 7 months. 


68 


Whitehead 


46 


1882 


Epithelioma. 


No recurrence in 8 months. 


69 


von Bergmann . 


54 


1882 


Carcinoma. 


Death after recurrence in 8 
months. 


70 


Burow 


44 


1882 


" 


Death from asphyxia 4^ 
months after. 


71 


Holmer 


63 


1882 


Epithelioma. 


Death from recurrence 4^ 
months after. 


72 
73 


Maydl 


50 

58 


1882 


Carcinoma. 


No recurrence in 16 months. 


Hahn 


1883 




Death in 4th week; purulent 
bronchitis. 






74 


Kocher 


59 


1883 


" 


No recurrence in 16 months. 


75 


Maydl 


45 


1883 


" 


Death 4th day from pneu- 
monia. 






76 


Leisrink 


72 


1883 


(C 


Death 4 months after from 
pneumonia. 


77 


von Bergmann . 


-- 


1883 


<< 


Death 4th day from pneu- 
monia. 


78 


Hahn 


52 


1883 


<c 


Death in 5 weeks from bron- 










chitis. 


79 


Hahn 


43 


1884 


c< 


Death from recurrence 15 






months after. 


80 


Vofft 


29 


1884 


<< 


Death 4 days after from pneu- 
monia. 




» v^c ...«.• .... 




81 


Hahn 


53 


1884 


<c 


Death on 4th day of pneu- 








monia. 


82 


Landerer 


36 


.... 


Adeno-car- 
cinoma. 


No recurrence in 18 months. 


83 


Hahn 


52 


1884 


Carcinoma. 


Death 3 months after from 










recurrence. 


84 


Novaro 


72 


1882 




Death 1% years after by 
feather blocking canula, no 
recurrence. 


85 


Winiwarter 


46 


1882 


" 


Recurrence 7 months after. 


86 


Winiwarter 


50 


1882 


<( 


Death 9th week from inani- 
tion. 


87 


Gussenbauer . . . 


63 


1883 


Epithelioma. 


CURE. Living in 1886, t,% 
years after. 


88 


Novaro 


52 


1882 


Carcinoma. 


Cure ? Living in Oct., 1884. 


89 


Pretorius 


54 


1883 


Epithelioma. 


Cure ? Living in 1885. 



2 74 CASE OF EMPEROR FREDERICK III. 

Table III. — Continued. 







c 


J? 






O tfi 


Operator. 


"^l 


i^ »J 


Disease. 


Subsequent History. 


cU 




S,o-i 


«oS 






2; 




< 









90 


Novaro 


54 


1883 


Epithelioma. 


Death in i month; pneu- 
monia. 


91 


Kocher 


-- 


1883 


Carcinoma. 


No local recurrence in 1884, 
but glands invaded. 


t92 


Jones, Th 


43 


1884 


Epithelioma. 


Was well 6 weeks after opera- 
tion. 


93 


Holmes 


63 


1884 


" 


Death from collapse in 48 
hours. 


94 


Durante 




1884 


Carcinoma. 


Death in two or three days. 


95 
tQ6 


Jordan Lloyd 

von Bergmann. 


51 
46 


1884 

1885 




Death from pneumonia in 6 

days. 
Reported cured in 6 weeks. 


Epithelioma. 


*97 


Hahn 


56 


1885 


Carcinoma. 


Death on loth day; bron- 
chitis. 


t98 


Park 




1885 


" 


Reported cured in 6 months. 


99 


Hahn 


60 


1886 


<( 


Death on 12th day; pneu- 
monia and erysipelas. 


100 


Morris 


59 


1885 


<( 


Death from collapse in 4 days. 


tioi 


Pean 


35 


1886 


«< 


Reported cured, no dates 
given. 










102 


Labbd 


51 


1886 


« 


Death from pneumonia on 
14th day. 






tio3 


Mickulicz 


-■ 


i8s6 


(( 


Reported cured in few weeks; 
no dates. 


104 


Hahn 


51 


1886 


<< 


Discharged cured ; recurrence 
and death probable. (Ope- 
rator's note.) 


105 


Labbe - . 


50 


1886 


Epithelioma. 


Death from recurrence in 4^ 
months. 






106 


Mickulicz 




.... 


Carcinoma. 


Death from starvation; power 
of swallowing not restored. 


tio7 


Axel Iverson. .. 


44 


1883 


a 


Death 3 months after. 


108 


Kosinski 


62 


1886 


" 


Death in 8 weeks of pneu- 
monia. 


109 


Axel Iverson... 


48 


1884 


Epithelioma. 


Reported well 3^ months after. 


110 


Pean 


65 


1886 


<( 


Death from broncho-pneu- 
monia, date not given. 


III 


Newman 


37 


1886 


'< 


No recurrence in 6 months. 


112 


Gardner 




.... 


" 


Living 4 months after opera- 
tion. 


113 
114 


Hogden 

Lange 








Death in 4 days. 
Death from septicaemia on 3d 
day. 


30 


i"879 


Carcinoma. 






* Partial resection had be 


en pet 


formed ( 


see table II., No. 


7) ; but recurrence having taken place 


total e 


xtirpation was perform 


ed wit 


ti the abc 


)ve result. 





t These cases are without value for statistical purposes, either having been reported too soon after 
the operation, or being too incomplete 



DR. MACKENZIE'S REPORT. 
Table III Continued. 



275 









.2 






'S ra 


Operator. 


'o'^ 




Disease. 


Subsequent History. 


dU 




&^ 


«o 






'& 




< 

60 


Q 






"5 


Billroth 


1879 


Carcinoma. 


Death from pneumonia in 3 












days. 


116 


Billroth 


26 


1880 


Epithelioma. 


Death from hemorrhage 8th 
day. 


117 


Reyher 


73 


1882 


Carcinoma. 


Death from recurrence in 9 
months. 


118 


Billroth 


-- 


1887 


<< 


Death same night attributed 
to syncope. 


119 


Dupont 


52 


1886 


(( 


Alive 5 months afterward. 


120 


Chiarella 


54 


1887 


" 


Death in 4 weeks from pneu- 
monia. 


*I2I 


Stelzner 




1887 


" 


Living 5 weeks after. 


*I22 


Novaro 


41 


1887 


Epithelioma. 


Alive 3 months afterward. 


*I23 


Novaro 


72 


1887 


" 


Alive I month afterward. 


124 


von Bergmann. 




1887 


Carcinoma. 


Death ; no date given. 


125 


Roswell 


63 


1886 


Epithelioma. 


Living 6 months afterward; 
no recurrence. 


126 


Schmiegelow . . . 


48 




Carcinoma. 


No recurrence in 9^ months. 


127 


Demons 


57 


1886 


Epithelioma. 


No recurrence 10 months after 
operation. 


128 


Gottstein 


49 


1884 


(C 


CURE. No recurrence y/^, 
years after. 


*I29 


Chiarella 


72 





Carcinoma. 


Reported well on 17th day, 
nothing more. 


130 


Hahn 


37 


1887 


li 


Death 4 weeks after opera- 
tion ; cause not stated. 


' Five c a s e s ~ 






commnnica- 












ted in a letter 












to the author 










131 


dated Sept. 


.. 







Death in a few days. 


132 


20, 1888, by 









Death in a few days. 


133 


< Dr. Pele- ■■ 









Death in a few days. 


134 


chin, Profes- 


.. 







Death in a few days. 


135 


sor of Sur- 
gery in the 
Imperial 
Academy, 
Petersburg. 








Death in 5 months. 


*i36 


Gardner 


62 


1887 




No recurrence in 6 months. 


*i37 


Hutley 




1887 


Epithelioma. 




*i38 


W. T. Ball 


-- 


1887 







* These cases are without value for statistical purposes, either having been reported too soon after 
the operation, or being too incomplete. 



276 CASE OF EMPEROR FREDERICK III. 

ANALYSIS OF TABLE III. 

Death took place in 36 cases in less than 9 days after the operation, 
and in 14 more within 5 weeks. Death, it will be seen, therefore, 
occurred as the immediate result of the operation in 50 out 
of 138 cases, or in 36-23 per cent. 

In the remaining cases, where death had occurred at the time the 
report was published, the fatal issue took place once within 7 weeks, 
four times in 8 weeks, once in 9 weeks, three times in 3 months, four 
times in 4 months, once in 19 weeks, seven times in 5 months, twice 
in 6 months, three times in 7 months, twice in 8 months, five times 
in 9 months, once in 10 months, once in 12 months, once in 131^ 
months, once in 14 months, once in 15 months, twice in 18 months, 
once in two years, and in three cases the exact date of death is not 
given. 

Recurrence is only known to have occurred in five cases in con- 
tiguous parts, and in one case (No. 91), it is said to have taken place 
" in the glands." Of course the removal of the entire organ tends to 
prevent recurrence. In one case (No. 104), the patient was dis- 
charged as having recovered from the effects of the operation, but 
the prognosis was so unfavorable that the operator notes recurrence 
and death as probable. 

Success occurred in 8 out of 138 cases, or 5-79 per cent. 

This operation, it will be seen, affords little prospect of success, and 
the conditions of existence after its performance are so utterly miser- 
able, the patient being almost completely cut off from intercourse 
with his fellow-beings, and having to take food in such a distressing 
way that suffocation is constantly imminent, and that death from 
starvation not unfrequently takes place. 



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THE ART OF BREATHING 

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supply, relations, embryology and history of development, comparative anatomy and 
important co-operative structures. The physiological part discusses the function of 
respiration generally, the movements and varieties of respiration, the action of the 
respiratory muscles, respiratory action and change of shape and respiratory rhythm of 
the diaphragm, control of the diaphragm's action, incidental functions of the diaphragm, 
change of shape in the trunli during respiration, differences in male and female 
breathing, certain natural phenomena that occur synchronously with the action of the 
diaphragm, relation of the circulation of the blood to the action of the diaphragm, 
actions of the diaphragm resulting from extraordinary causes, the comparative 
physiology of the diaphragm, and functional development of the organ. Under the 
hygienic heading is considered the diseased conditions to which the diaphragm is 
subject, the conditions essential to its nurture and healthy action, corset and waist- 
constriction, special exercise of the diaphragm, how to breathe, etc. An appendix, 
written a year subsequent to the essay itself, gives practical conclusions and advice. 
The book is valuable both for the medical and the vocal professions. 



Flexible Cloth, $1., Postpaid. 

Address the Publisher, EDGAR S. WERNER, 48 University Place, 
NEW YOKK. 

HYGIENE 

OF THE 

VOCAL ORGANS. 

A PRACTICAL HANDBOOK FOR SINGERS 
AND SPEAKERS. 

Illustrated, and telling how the Singing and Speaking- 
Voice may be Trained and Preserved ; and showing what 
is beneficial and what injurious to the voice. 



By SIR MORELL MACKENZIE. 



CLOTH, $1.50, Postpaid. 

Address, EDGAR S. WERNER, 48 University Place, 
NEW YORK, 



Practical Method of Singing ! 

Based upon Natural and Artistic Principles, including- a Thorough Course of Training in 
the Art of Breathing and Voice-Building, together with a carefully prepared set of 

VOCAL EXERCISES, 

the whole forming a Plain, Comprehensive and Progressive Course for the 

CULTIVATION OF THE VOICE. 

Designed both for Teachers' use and for Students' Self-Instruction. 

By JOSEPHINE KAND. 



The principal sections of the book are : 

Theory and Practice, Preparatory Study, Art of Breathing, Training of the Tongue, 
Study of the English Language. Registers, Hygiene of the "Voice, Design of the Exer- 
cises, Exercises in Kespiratory Technique, Exercises for the Flexibility of the Jaw, the 
Lips and the Soft-Palate, Position of the Mouth in Singing, Exercises in Vocal Tech- 
nique, Color, Scale Practice, the Trill, Staccato Singing, Faults to be Avoided, Sight 
Reading, Exercises with Accompaniment, Expression. 



Of the many Testimonials a few are given : 

J. C. liAKTI^ETT, Opera Singer. 

Your book contains many things of the greatest importance to the vocalist, and your 
way of expressing the ideas is very, very clear and easily understood. It is a book of 
great assistance to both pupils and teachers, and it needs no recommendation after even 
a slight examination. 

J. A. BUTTERFIELD, Vocal Teacher and Composer. 
I have given your book a thorough examination and admire it exceedingly. It is re- 
freshing to read your remarks on the art of breathing. The study of the English lan- 
guage article is right to the point, and ought to be read by every student. I am fully 
with you vidth reference to the physiology of the voice. In short, you have said so many 
sensible things, and suggested so many good devices, that 1 am sure the true teacher 
must hail the advent of your work as an assistant he cannot afford to be without. 
WILLIAM H. DANA, Principal of Dana's Musical Inst. 
I am highly pleased with the book, and am prepared to endorse it as being the most 
practical treatise on the subject ever reviewed by me. 

^VILLIAM E. CHANDLER, Vocal Teacher. 
The ideas you advance for voice-cultivation I heartily endorse, as I have worked on 
the same plan for many years. 

B. T. HAMMOND, Vocal Teacher, 
I am a disciple of William Shakespeare. 1 have found in your book many points with 
which I most heartily agree. 

WALDO S. PRATT, Vocal Teacher. 
It is very practical, wise and clear, and a valuable contribution to the study of voice- 
building. 

HENRIETTA BEEBE-LAWTON, Vocal Teacher and Singer. 
I can see readily how useful your excellent book will prove to teachers. 
A. C. GUrTEHSON, Vocal Teacher and Director. 
It is one of the best methods and treatises on the cultivation of the voice in singing, 
and the best aid to the teacher, that I have ever examined. Could I have had the prin- 
ciples of the management of the breath and of the muscles taught me when I was study- 
ing, that you have explained as thoroughly as can be done by written language, I could 
have shortened my years of study very much. 

Mrs. B. F. D. HAZZAN, Director of Conservatory. 
It is a very timely and useful book. At the beginning of our next school year I shaU 
make an order for as many as I can use. 

D. B. HUNT, M.D. 
I have read all the chapters and can find nothing to, add to your careful research and 
study. I have shown it to several of my patients who are singers, and they all praise it. 



Sheet music size, price $1, postpaid. (Redviced from S3.) 
Address the Publisher 

EDGAR S. WERNER, 4-8 University Place, New York. 



THE WORKS OF 

Lennox Browne ^EmilBehnke 



VOICE. SONG AXP SPEECH. Price »3. 

A Practical Guide for Singers and Speakers from the Combined View of the 
Vocal Surgeon and the Voice Trainer. 

SCIENCE AND SINGING. Price 40 cts. 

Some of the Sub.tects Discussed : Necessity for Scientific Knowledge. 
Instances of Unscientific Teaching, Opposition to Scientific Teaching, Remon- 
strance against Opposition, Influence of Eye to Aid the Ear, Advantage of 
Laryngoscopic Observation, Testimony in Favor of Laryngoscopy, Mechanical 
Aspect of Breathing, Carbonic Acid Gas in Atmosphere, Poisonous Air in 
Theatres, Effect of Poisonous Air on the Voice, Smoking-Concerts, Artificial 
Italian Air, Supposed Vocal Supremacy of Italy, Italian as Language of Song, 
Supposed Supremacy of Italian Composers, Peroxide of Hydrogen, Ammonia a 
Poisonous Gas, Caustic Ammonia not found m Nature, LTselessness of Artificial 
Voice Mixtures, Other Methods of Purifying Atmosphere, Ozone in Open Electric 
Lights, Science in Relation to Tone-Production, Questions Concerning the Regis- 
ters, Wesley Mills on the Registers, Illustrating Thick and Thin Registers, Early 
Education of the Voice, Voice to be Rested During '■ Break," Herbert Spencer on 
Science and Art. 

SOPRANO VOICE-TRAINING EXERCISES. Price 60 cts. 

43 Pages of Progressive Lessons for Acquiring Resonance, Attack and Flexi- 
bility for the Whole Compass of the Voice, Exercises for Sustained Tones, 
Chromatic Phrases, Transition from One Register to Another, The Major and 
Minor Scales, Scale Passages, Arpeggios, Chromatic Scales, The Turn, The Shake, 
and Other Ornaments and Graces. 

MEDICAL HINTS ON THE PRODUCTION AND MANAGEMENT OF THE SING - 
ING-VOICE. Price 30 cts. 

THE CHILD'S VOICE. Price 60 cts. 

Its Treatment with regard to After-Development. 

VOICE-USE AND STIMULANTS. Price 60 cts. 

THE MECHANISM OF THE HUMAN VOICE. Price »1. Illustrated. 



Any of the above Books sent on receipt of price. 



Address, 

EDGAR S. WERNER, 

48 University Place, NEW YORK. 




Manufacturers ■ of 

lle©tf®»iif|liil 

295 & 2g7 Fourth Ave., 

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Estimates and Inforjuation Promptly and Cheerfully Furnished. 



Address, 

EDG^R S. WERNER, Publisher, 

48 University Place, NEW YORK. 



/TOLDEN'S 



ORIGINAL label: 

"Colden's Liebig's Liquid Extract 
of-Beef-and Tonic Invigorator." 



\^ LIQUID BEEF TONIC. 

An Invaluable Aid In tlie Treatment; of all Cases of Debility. 

^^° Established 20 Years. ^ ^ Endorsed by Eminent Physicians. ^g°Beware 

of Imitations. '^^ ^ Essentially diff erent from -all other Beef To7tics. 

COLDEN'S LIQUID BEEF TONIC consists of th.e:Extract of Beef (by Baron Lie 
big's process), spirit rendered non-injurious to the most delicate stomach by 
extraction of Fusel Oil, Soluble Citrate of Iron, Cinchona; Gentian. An official analysis 
of this preparation by the eminent chemist, ARTHUK HILL HASSALL, M.D., F.R.S., 
and an endorsement of by Sir ERASMUS WILSON, F.ItS., is printed on the label of 
each bottle. 

In the treatment of all casesof Debility, Convalescence from severe illness. 
Anaemia, Malarial Fever, Chlorosis, Incipient Consumption, Lack of Neive 
Tone, and of the Alcohol and Opium Habits, and all maladies requiring a 
Tonic Nutrient, it is superior to all other preparations. 

It acts directly on the sentient gastric nerves, stimulating the follicles to secretion, 
and gives to weakened individuals that first prerequisite to improvement, an appetite. — 
By the urgent request of several eminent members of the medical profession, I have 
added to each wineglassf ul of this preparation two grains. of SOLUBLE CITRATE OP 
IRON, and which is designated on the label WITH IRON, "No. 1;" while the same 
preparation, WITHOUT IRON, is designated on the label as " No. 2." 

•^^^ I will, upon application, send a sample bottle of COLDEN'S LIQUID BEEF 
TONIC to any physician in regular standing. Please ask your Dispensing Druggist (if he 
has not already a supply) to order it. In prescribing mention "COLDEN'S," me.,^''EXT. 
CABNISFL. COMP. (GOLDEN):' Put up in pint bottles, and SOLD BY WHOLE- 
SALE AND RETAIL DRUGGISTS C^NEBALLT TEROUGHOUT THE UNITED 
STATES. 

C. N. CRITTENTON, Sole Agent, 115 Fulton Street, New York. 



H 



YDROLEINE 



(HYDRATED OIL.) 



FOR CONSUMPTION AND WASTING DISEASES. 

Produces Rapid Increase In Flesh and Strength. 



FORMULA. 

Each Dose of Two Teaspoonfuls equal tolSO djfops, contains : 

Pure Cod Liver Oil. . 80 m. (drops.) I Soda 1.3 Grains. 

Distilled Water 35 " | Salicylic Acid 1.4 

Soluble Pancreatin .. . 5 Grains. | Hyochollo Acid . .. .1.20 " 

DOSE — Two teaspoonfuls alone, or with twice! 'the quantity 
of water to be taken thrice daily after meals. 



Each bottle in nutritive value exceeds t«n times the same bulk 
of Cod Liver Oil. It is economical in use and certain in results. 

The principles upon which this discovery is base'd have been described in a treatise 
on "The Digestion and Assimilation of Fats in the Human Body," by H. C. Bartlbtt, 
Ph. D., F. C. S., and the experiments which were made, together with cases illustrating 
the effect of Hydrated Oil in practice, are concisely stated in a Treatise on "Consump- 
tion and Wasting Diseases," by G. Overbnd Dbewrt, M. D. 

Copies of these works sent free on application. 
Sold at all Drugstores, at $1.00; per bottle. 

O. N. CRITTENTDOU, 

Sole Agent for the United States. j^i^ Fulton Street, NEW YORK. 

A sample of Hydroleine will -be sent free upon application, to any physician 
(inclosing business card) in the United, States. 






4A. 




LIBRARY OF CONGRESS 



029 894 789 4 




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